Gluten sensitivity is a common gluten-related condition, affecting a significant portion of the population. Symptoms of gluten sensitivity can be similar to those of irritable bowel syndrome, celiac disease, and wheat allergy; however, it is recognized as a distinct condition. The lack of conventional diagnostic markers makes diagnosis challenging, leaving many without a clear diagnosis or solution to their symptoms. (2)
This article will discuss gluten sensitivity, a functional medicine approach to evaluation and diagnosis, and commonly implemented, evidence-based natural strategies that may be used to support individuals with this condition.
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What is Gluten?
Gluten proteins are stored in the endosperm of wheat and related grains. The three main naturally gluten-containing grains are wheat, barley, and rye. Other gluten-containing wheat derivatives include wheatberries, spelt, and farro.
Wheat gluten is composed of gliadin and glutenin. Gliadin is the protein fraction often associated with adverse reactions to gluten.
Although some grains do not contain gluten, they have proteins that appear and act very similarly to gluten in the body (referred to as "cross-reactivity"). The avenin protein found in oats is one of these; it is the reason some people with gluten-related disorders may not tolerate oats in their diet.
What is Gluten Sensitivity?
Gluten sensitivity, non-celiac gluten sensitivity (NCGS), and gluten intolerance all refer to the same digestive condition. Gluten sensitivity involves the presence of intestinal and/or extraintestinal symptoms after consuming gluten. These individuals do not have celiac disease or wheat allergy but may experience symptomatic improvement when gluten is reduced or eliminated from their diet. (1, 2)
NCGS is considered less severe than celiac disease because it does not typically cause the same extent of small intestinal damage and inflammation. However, some research suggests that gluten exposure may lead to small intestinal changes and increased intestinal permeability in individuals with NCGS (5, 6).
Gluten sensitivity is a distinct condition from celiac disease and wheat allergy. For NCGS to be considered, celiac disease and wheat allergy must be ruled out. Celiac disease is an autoimmune condition that results in inflammation and damage to the small intestine after consuming gluten. Celiac disease is diagnosed by key cellular changes on small intestinal biopsy, and serological testing usually confirms the presence of celiac-associated autoantibodies. Wheat allergy is an immune-mediated allergic response by which the consumption of wheat results in allergic symptoms, including hives, rash, swelling of the skin, shortness of breath, wheezing, and swelling of the airways. Wheat allergy is confirmed by measuring IgE antibodies specific to wheat by skin prick or blood testing. (3, 4)
Gluten Sensitivity Symptoms
Gluten sensitivity may trigger gastrointestinal (GI) symptoms after consuming gluten-containing foods. Symptoms related to gluten sensitivity can occur hours to days after consumption of the trigger food. Bloating, abdominal pain, diarrhea, nausea, and reflux are reported to be common GI symptoms. (7)
Gluten sensitivity can also be associated with non-digestive symptoms. Extraintestinal symptoms can vary widely, including headache, fatigue, brain fog, muscle and joint pain, skin rash, and mood changes. (7)
Top 5 Functional Medicine Tests for Gluten Sensitivity
While there are many tests available, here are the top 5 tests that functional medicine providers may consider for gluten sensitivity:
Celiac Disease
Celiac disease must be ruled out before considering a diagnosis of gluten sensitivity. The gold standard for celiac disease diagnosis is a small intestinal biopsy for visual confirmation of small intestinal damage and inflammation. Histological villous atrophy is the characteristic diagnostic feature of celiac disease. (8)
Given this procedure's invasiveness, serological testing while the patient is consuming a gluten-containing diet is often recommended. The American College of Gastroenterology recommends using immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody as first-line screening (8). Functional medicine doctors may order a more comprehensive antibody panel, which includes IgA and immunoglobulin G (IgG) antibodies to TTG, endomysium, and deamidated gliadin peptide.
Wheat Allergy
A blood test negative for wheat IgE antibodies can help rule out wheat allergy before considering gluten sensitivity (4).
Gluten Sensitivity
There are no conventional biomarkers for NCGS, allowing many cases to go undiagnosed in the allopathic setting (2). Specialty blood panels measuring antibodies and the immune response to various wheat- and gluten-related proteins may help to assess gluten reactivity and allow for better recognition of gluten sensitivity.
Gluten Cross-Reactivity
The Cyrex Array 4 panel identifies food sensitivities to foods that frequently cross-react with gluten-containing foods. This panel can be helpful for patients beginning to implement dietary modifications or who continue to experience NCGS-like symptoms despite eating a gluten-free diet.
Comprehensive Stool Testing
NCGS has been documented to be associated with dysbiosis within the gut microbiome. Dysbiosis can further exacerbate intestinal inflammation and GI symptoms, potentially increasing the severity of NCGS. A comprehensive stool test assesses the gut microbiome, along with measuring other markers of digestion and inflammation, for an extensive gut-health evaluation.
Other Lab Tests to Check
Due to a phenomenon called molecular mimicry, gluten sensitivity and autoimmune thyroid disease are often discussed together. A comprehensive thyroid panel, measuring multiple markers of thyroid function and autoimmunity, can screen for thyroid autoimmunity and hypothyroidism in individuals with gluten sensitivity.
Integrative Medicine Approaches for Gluten Sensitivity
Functional medicine practitioners utilize the information they gain from the lab tests and create thorough plans that may consist of the following:
Nutrition for Gluten Sensitivity
First-line strategies for individuals with gluten sensitivity often involve reducing food sensitivities: gluten-containing foods and any identified cross-reactive foods. A gluten-free diet (GFD) is often suggested for a period of time for individuals with gluten sensitivity. It is debated whether individuals with NCGS require a life-long GFD. While some continue to have wheat triggers after several years of dietary changes, evidence suggests many individuals have gluten-tolerance thresholds and may reintroduce gluten into the diet in small amounts. (1, 7)
Additionally, some individuals with gluten sensitivity may benefit from reducing the consumption of high-FODMAP foods. A low FODMAP diet aims to reduce certain types of carbohydrates (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) from the diet. Research suggests a low FODMAP diet may help reduce GI symptoms in individuals with NCGS and wheat-sensitive irritable bowel syndrome.
Supplements & Herbs for Gluten Sensitivity
Endopeptidases, digestive enzymes specific to breaking down gluten proteins, may support the digestion of gluten and help reduce its effects in sensitive individuals. These digestive enzymes may assist in digesting small amounts of gluten in cases of accidental exposure but should not replace a GFD. (9)
Supporting a healthy gut microbiome and addressing dysbiosis may be beneficial in managing NCGS and maintaining overall gut health. The gut microbiota can influence the digestion of gluten proteins, modulate intestinal permeability, and regulate immune responses. Probiotics containing Lactobacillus spp., Bifidobacterium spp., and Saccharomyces boulardii have been shown to support intestinal health and may aid in the digestion of gluten in gluten-sensitive individuals. (9)
Utilizing nutritional supplements and herbs to support the small intestinal barrier once gluten has been reduced or eliminated from the diet may help in maintaining gut health. L-glutamine, zinc carnosine, and demulcent herbs (e.g., aloe, deglycyrrhizinated licorice, and marshmallow) are sometimes suggested by functional providers for gut-support protocols.
Summary
Gluten sensitivity is a type of adverse reaction to gluten-containing foods, distinct from celiac disease and wheat allergy. Because conventional biomarkers are unavailable to diagnose gluten sensitivity, it often goes undiagnosed, causing many challenging digestive and extraintestinal symptoms similar to celiac disease. Functional lab panels may assist in the recognition of gluten sensitivity and the identification of cross-reactive foods. A gluten-free diet and nutritional supplements to support gluten tolerance and gut health are often suggested by functional medicine practitioners to help manage gluten sensitivity.
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