Non-Celiac Gluten Sensitivity

Dr. Guillory's article on non-celiac gluten sensitivityNon-Celiac Gluten Sensitivity 

I’m glad to see that Non-Celiac Gluten Sensitivity (NCGS) is getting the attention that it deserves.  As someone who has been interested in food intolerances and food sensitivities during my 28 years of practice, I am compelled to comment on this article and share my thoughts with you.

Let’s talk about what I think we all can agree on.  First, there has been an alarming 400% rise in the past few decades in celiac disease (1 in 3000 versus 1 in 120). This is an autoimmune disorder which can be diagnosed by characteristic histologic changes after endoscopy or by antibody testing.  If there had been a 400% rise in cancer or heart disease, the scientific community would be desperately looking for the cause.  Celiac is not a trivial disease which causes uncomfortable digestive symptoms, there are lots of comorbidities.  In fact, many celiac patients have no digestive symptoms at all.

Here is where we may have divergent views.

With this increase in celiac disease, there has also been an increase in other autoimmune disorders, including Hashimoto’s thyroiditis, rheumatoid arthritis, SLE etc.

Is there a connection? I believe there is and it might be explained by the notion of “molecular mimicry”.  Alternatively, it may be the result of gluten causing overexpression of Zonulin, the protein molecule which regulates intestinal permeability, which in turn leads to increased mucosal permeability or “leaky gut”.  I know “leaky gut” sounds so goofy.  It’s like saying tennis elbow versus “lateral epicondylitis.”

So, you’re probably now wondering why have celiac disease cases skyrocketed the past few decades? Has the number of people who carry the gene for celiac (25% of the population) increased?  I think it is unlikely that our genes could’ve changed that much over this rather short time period to account for the increase incidence.

According to Dr. Alessio Fasano, the researcher who discovered Zonulin, 3 things need to occur for celiac disease to present itself.  First, you have the gene, then you are exposed to gluten, and finally, something else causes increased mucosal permeability which in turn leads to expression of the celiac gene.  Could it be that we are seeing more celiac because the modern day hybrid wheat has a higher gluten content?  It may be that we are seeing more celiac as the result of increased mucosal permeability caused by a variety of contributing factors, including medications, diet or gastrointestinal infections.

And what of the mystery of Non-Celiac Gluten Sensitivity.  Since there are no accepted biological markers to make the diagnosis, how do you determine if you might have this  condition?  [There are some specialty labs that offer testing which might prove to be useful down the road, but let’s just say for the time being, there are no blood tests recognized by conventional medicine to diagnose NCGS].  So far, the only way to know if you might have NCGS is to go completely off gluten for 2-3 months and see how you feel.

I wrote the first book for patients with IBS in 1989 and 3 subsequent editions of a second book on this topic.  I have been doing diet diaries, elimination diets and various forms of dietary manipulation with IBS patients for more than 20 years.  I conclude that  many patients symptomatically improve when they avoid gluten.

Obviously there are other dietary triggers for IBS, such as dairy.  Not only did their digestive complaints improve but many other symptoms resolved.  With gluten elimination, I have noted a decrease in inflammatory markers such as CRP, reversal of autoimmune/inflammatory symptoms, and improvement in liver function tests in patients diagnosed with nonalcoholic fatty liver disease.

What is the incidence of NCGS? As someone who has recommended gluten elimination for many years, I have found that to varying degrees the majority of patients who eliminate gluten completely from their diet feel better and this approaches 100%.  Don’t just take my word for it.  I have scores of medical students who have rotated through my office who will also attest to this.  I find it a shame that as practicing physicians, our experience, observations and intuition are not considered as valuable as they once were.  (Note-you can have NCGS with or without having the genes for celiac.)

I agree wholeheartedly with Dr. Fasano who states “if you’re suffering with symptoms that make your life miserable and you’ve investigated all possible causes, I don’t see anything wrong with going on a gluten-free diet”.