Understanding Non-Celiac Gluten Sensitivity and Digestive Health

Gluten-related health conditions have gained increased attention as some individuals report adverse reactions to gluten-containing foods.

While celiac disease and wheat allergy are long-standing, well-known conditions, non-celiac gluten sensitivity (NCGS) was discovered more recently. 

Without a gold standard test for NCGS, its prevalence is unclear, with some sources reporting up to 6% and others reporting 13% or more of people in the United States affected. Although NCGS is less understood, it may impact the quality of life for some individuals.

This article aims to explain NCGS, its symptoms, how it affects gut motility, and the foods that it is necessary to avoid. It provides healthcare providers and patients with the knowledge to care for NCGS effectively.

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What is Non-Celiac Gluten Sensitivity (NCGS)?

NCGS is currently described as a condition in which some individuals report adverse symptoms after consuming gluten, a protein found in wheat, barley, and rye, without the autoimmune characteristics of celiac disease or the allergic reaction associated with wheat allergy. 

Celiac disease damages the intestinal mucosa and is diagnosed through specific immunoglobulin serology, antibody testing, and intestinal biopsies. 

A wheat allergy can be an IgE-mediated or non-IgE-mediated allergic response to wheat ingestion or inhalation. It can be diagnosed by measuring serum immunoglobulin E (IgE) levels after wheat ingestion or other levels of antibodies.

On the other hand, there is no definitive biomarker or gold standard test for diagnosing NCGS. 

A diagnosis of NCGS is often considered after ruling out other conditions, such as celiac disease, wheat allergy, and irritable bowel syndrome, as well as noting improvements after eliminating gluten in the diet.

Symptoms of Non-Celiac Gluten Sensitivity

NCGS can present with a wide range of symptoms, broadly considered as gastrointestinal or extra-intestinal manifestations. Also, there are common overall symptoms that many individuals with NCGS report experiencing.

Common Symptoms

NCGS often causes these common overall symptoms:

• Abdominal pain or cramping
• Changes in bowel habits (diarrhea or constipation)
• Bloating
• Headaches
• Fatigue and low energy levels
• Joint and muscle pains

Digestive Symptoms

Gastrointestinal symptoms are commonly reported in NCGS and are often part of the presenting concerns. They can include abdominal pain, changes in bowel habits (diarrhea, constipation, or both), bloating, and gastrointestinal discomfort after consuming gluten. 

This can be difficult, as these symptoms often mimic other common conditions–like irritable bowel syndrome (IBS)–making it challenging to identify gluten as the cause of symptoms.

Extra-Intestinal Symptoms

In addition to gastrointestinal manifestations, NCGS can cause symptoms in other areas of the body, making it difficult to correlate with a dietary etiology. 

Some individuals with NCGS report symptoms such as skin rashes, brain fog, mood changes (e.g., anxiety or depression), joint discomfort, and muscle aches.

Signs of Gluten Sensitivity

Because the signs of gluten sensitivity may be nonspecific and often confused with other conditions, NCGS may be difficult to suspect. 

One of the most effective ways to identify gluten sensitivity is through symptom tracking. Using a food diary, tracking app, or food elimination strategies can help pinpoint gluten as the source of symptoms by noting that symptoms occur following gluten consumption.

Because NCGS does not cause damage to the intestinal mucosa, nutrient malabsorption is not commonly associated with NCGS, in contrast to celiac disease. Therefore, clinicians may not be clued into the possibility of gluten sensitivity based on objective findings alone. 

Instead, having open patient-clinician communication is imperative to identify a problem with gluten consumption.

Foods to Avoid with NCGS

Managing NCGS often involves adhering to a gluten-free diet guided by a healthcare professional.

This necessitates understanding what foods contain gluten, where hidden sources of gluten may exist, how cross-contamination may be a concern, and what safe alternatives are available.

Gluten-Containing Foods

Several types of foods are the primary sources of gluten.

• Wheat and its derivatives are the most common sources of gluten. Examples include breads, pasta, crackers, cereals, snacks, and baked goods.
• Barley, often found in malt and beer and as a grain, also contains gluten.
• Rye, a grain used in certain bread and cereals, has gluten.

Hidden Sources of Gluten

Following a gluten-free diet doesn't just mean avoiding these primary sources of gluten. Gluten can be hidden in unexpected food and drink items for flavor, texture, shelf-stability, and others. 

Consider these potential sources of hidden gluten:

• Processed foods like soups, sauces, and salad dressings may contain gluten as a thickening agent or for shelf stability.
• Medications and supplements often use gluten as a binding agent.
• Certain flavored beverages and snacks rely on gluten for their flavors.
• Dry seasonings, seasoning packets, and processed meats may have gluten to help with texture and preservation.

When identifying hidden sources of gluten, it is critical to read product labels and follow FDA allergen labeling guidelines carefully.

Cross-Contamination with Gluten

Ingesting even small amounts of gluten may trigger symptoms for those with gluten sensitivity.

This can include cross-contamination from cooking foods in the same pans or oils, using the same utensils for gluten and gluten-free foods, handling gluten-containing and gluten-free foods without washing hands or changing gloves, or consuming cross-contaminated processed foods.

Preparing meals at home gives individuals more control over avoiding gluten exposure. 

However, while many restaurants offer ingredient transparency and are willing to take measures to ensure gluten avoidance, many restaurant staff may not be knowledgeable about gluten, and it is often impossible to guarantee that restaurant-prepared foods are entirely gluten-free. 

Discussing dietary restrictions with restaurant wait staff and chefs can help minimize the risk of exposure to gluten.

Safe Alternatives

Naturally gluten-free grains and foods can provide safe and nutritious options for those with NCGS:

• Grains and pseudograins, like rice, quinoa, and millet, are naturally gluten-free and provide necessary micronutrients.
• Gluten-free oats are a rich source of dietary fiber and complex carbohydrates (be sure they are labeled gluten-free to avoid the risk of contamination).
• Legumes, fruits, and vegetables are whole, anti-inflammatory foods that are gluten-free and provide essential micronutrients and antioxidants.

Impact of Gluten on Gut Motility

Emerging research explores how gluten ingestion might impact gut motility, potentially disrupting digestion and contributing to symptoms such as diarrhea or constipation.

Gut-Brain Axis

The gut-brain axis is a communication system between the gut and the brain. It plays a vital role in gut motility, defined as food movement through the digestive tract. 

Some research suggests that gluten may influence the gut-brain axis, potentially contributing to symptoms such as diarrhea, constipation, or abdominal discomfort.

Mechanisms

While the exact mechanisms by which gluten may impact gut motility remain under investigation, proposed theories include:

• Inflammation: Gluten can cause inflammation, increasing permeability, and dysregulated gut motility.
• Stress: Elevated stress levels can adversely impact gut motility, also through the gut-brain axis.
• Changes in the gut microbiome: Gluten may impact the gut microbiome's composition, significantly influencing gut motility.

Clinical Evidence

Emerging evidence suggests that NCGS may be associated with changes in small intestine transit time and contractility. This supports the effects of NCGS on gut motility, which directly correlates with the gastrointestinal symptoms of NCGS.

Management of NCGS and Motility Issues

Effective management of NCGS focuses primarily on dietary changes. Other strategies, like lifestyle changes and potentially medical treatments, are also essential.

Dietary Interventions

A gluten-free diet is fundamental to managing any gluten sensitivity, including NCGS. Following a gluten-free diet is challenging, given the prevalence of gluten in the food supply and the hidden sources of gluten that may be difficult to detect. 

Working with a knowledgeable professional can help institute a healthy, gluten-free diet.

Ensuring nutritional adequacy is key, and this is also where a knowledgeable professional can be helpful. 

Obtaining necessary nutrients without consuming gluten is possible but requires careful planning, as gluten-containing grains often provide fiber and micronutrients.

In addition, getting adequate dietary fiber is crucial for gut health, as it helps support a healthy gut microbiome, which also impacts gut motility.

Lifestyle Changes

Because increased stress can disrupt gut motility, effectively managing stress through exercise and mindfulness practices may help manage NCGS. 

In addition, engaging in regular physical exercise positively impacts gut motility and healthy digestion. 

Medical Treatments

Medical treatments may be beneficial for ongoing symptoms related to NCGS. 

Healthcare providers may recommend prebiotics, such as dietary fiber, and probiotics to support gut microbiome balance and overall digestive health.

Fiber may also help modulate bowel regularity. Clinicians may also recommend other specific medical treatments.

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Key Takeaways

• NCGS is a condition that causes adverse symptoms after gluten consumption.
• NCGS is distinct from other gluten-related sensitivities, such as celiac disease and wheat allergy, and it is similar yet different from irritable bowel syndrome.
• Symptoms of NCGS can be gastrointestinal and extra-intestinal, yet most people experience abdominal pain, changes in bowel habits, and bloating.
• Diagnosing NCGS can be challenging due to the lack of a gold standard diagnostic marker. Ruling out similar conditions (like celiac disease and wheat allergy) is necessary in making the diagnosis.
• Following a gluten-free diet is the mainstay of NCGS management. Lifestyle modifications, including stress management and regular exercise, also help improve gastrointestinal functions.
• Adding dietary fiber, prebiotics, and probiotics may support gut health in individuals managing NCGS symptoms.
• Following a gluten-free diet can be challenging, as gluten is a common ingredient in foods. It is crucial to identify sources of gluten (including more hidden sources) and to maintain a balanced, gluten-free diet to ensure nutritional adequacy.