I Don’t Have Celiac Disease…Should I Avoid Gluten?
If you missed it, be sure to check out part 1 of this series, where we reviewed Celiac disease, a condition that has become increasingly prevalent but still frequently missed by healthcare providers. To round out this discussion on gluten, this week we’ll be discussing answers to another common question: if I don’t have Celiac, should I still avoid gluten?
As you may suspect, the short answer is maybe. For a long time the prevailing idea (an idea that unfortunately still exists in some circles) was that only those with Celiac needed to worry about gluten consumption. The reality is that sensitivity to wheat/gluten outside of Celiac disease exists, but it exists—like many things in life—on a spectrum. We can think of this spectrum ranging all the way from severe Celiac disease on one end, to no sensitivity on the other. As you read in part 1, even within the group of people who have diagnosed Celiac disease, symptom type and severity varies widely.
There are two predominant ways in which somebody without Celiac disease can have issues with gluten-containing products: wheat allergy, and non-Celiac gluten sensitivity (NCGS). I’ll first discuss wheat allergy before moving to NCGS.
An allergy is an immunological reaction in which the immune system recognizes an antigen (in this case, wheat) and reacts by releasing IgE antibodies. These antibodies then bind to mast cells, which release mediators—the most important of which is histamine—that cause allergic symptoms such as hives, redness, swelling, itchiness, palpitations, sneezing, GI symptoms and runny nose. When someone has a true wheat allergy they will consistently have some collection of these symptoms soon (within minutes to a couple hours) after consuming wheat.
Again, this may exist on a spectrum, ranging from very mild symptoms to full on anaphylaxis if there is a severe allergy. If there are exclusively GI symptoms without any other allergic symptoms, we would think more about NCGS as a potential problem. There are a few other much more rare ways in which wheat allergy or sensitivity can present, but they are beyond the scope of this article.
How is wheat allergy diagnosed? There are many different testing options, with different pros and cons. The “gold-standard” would be a blinded, controlled oral food challenge by an allergist.
However most people won’t need that. If you notice symptoms after consuming wheat, and also have a positive IgE antibody blood test, you likely have a wheat allergy.
Non-Celiac Gluten Sensitivity
NCGS is an umbrella label for people who seem to feel better avoiding gluten but don’t have Celiac disease (or wheat allergy). Those with NCGS may feel digestive symptoms like abdominal pain, constipation, diarrhea, or bloating, but they also could experience fatigue, anxiety/depression symptoms, brain fog, worsened pain, or many other potential symptoms after consuming gluten. NCGS exists on a spectrum and some may notice only minor symptoms, or nothing at all until they try eliminating gluten and recognize they feel better off of it. Others may notice significant symptoms and an obvious connection.
For some time, many within the medical field discounted the possibility of sensitivity to gluten outside of Celiac disease, but NCGS is now a scientifically-validated condition. As an example, one study from 2016 investigated what happened when people who reported wheat sensitivity, but who did not have Celiac or wheat allergy, consumed wheat. Researchers found that, in these subjects, wheat induced immune-system activation and intestinal epithelial damage, leading to “leaky gut”— an issue commonly seen in our practice, and a topic I may cover in a future blog.
How prevalent NCGS is is still unclear. Some voices in the health and wellness space will claim that most of us are sensitive and that most people would be better off completely avoiding gluten. So far most of the research would refute that statement. One recent large study in Italy found a prevalence of NCGS of 3%—a significant number (this would be nearly 10 million people in the United States), but probably not nearly as common as many have proposed.That being said, it is possible that NCGS would be more prevalent in the United States as compared to Italy. And we may never have very clear statistics, given the spectrum of sensitivity and that sensitivities can change over time.
The Bottom Line
Wheat/gluten allergies and sensitivities can be confusing. Thankfully, there is a simple (and free!) way to figure out if gluten is likely a problem for you or not. If you are unsure about how gluten is affecting you, you can try a strict gluten-free diet for at least 4 weeks, and then attempt to reintroduce gluten into your diet. If there is inflammation in your body from consuming gluten, going without it for just 4 weeks should bring it down and you should be able to notice improvements in your symptoms. If you don’t notice anything after removing, you could notice a worsening of symptoms upon reintroduction of gluten-containing foods. If you notice either an improvement in symptoms when off gluten, or worsening of symptoms going back on, avoiding wheat is probably best. However, if you do not notice much of anything, wheat likely isn’t a problem for you! (You can also ask your doctor to check gluten IgG antibodies on blood work, as even most commercial labs do this test these days.)
It is important to remember that, even if you do have NCGS you may still be able to consume gluten from time to time, depending on how aggravating gluten is for you. Additionally, your overall gut health can have a lot to do with how you tolerate gluten, and for some patients what appears to be a sensitivity to gluten can actually be a sensitivity to FODMAPs in wheat. Some patients will handle wheat or FODMAPs better after improving the health of their gut/microbiome by working with a functional medicine practitioner. What appears to be a gluten sensitivity may also actually be a yeast overgrowth or hypersensitivity, since most wheat-containing products are also high in simple white carbohydrates and contain yeast in them.
I want to stress that for most people wheat can be a part of a healthy diet, and unfortunately there is an idea that has grown in popularity that everyone should avoid wheat/gluten for optimal health. There is no need to completely avoid it if you have done the above experiment and have found that you tolerate it well. I just recommend making sure it is whole-grain wheat, and ideally organic when possible to avoid glyphosate contamination. And I also recommend focusing on other nutrient-dense foods first, especially fruits, vegetables, unprocessed meat, eggs, nuts and seeds.