Gluten and NCGS 2

Gluten (What You Need To Know)

Gluten and NCGS

Gluten. Nowadays everyone has heard about it and has an opinion about it. Sadly, that opinion is hardly ever based on actual facts, and it is hard for people to actually explain something about gluten once they are asked about it. People base their opinion all the more on the hype that has been created around it.

Personally, I think it’s a bad idea to be avoiding gluten if you don’t need to. Only if you get real physical complaints or have an actual immune response to gluten (celiac disease or dermatitis herpetiformis), it is a good idea to stop eating gluten. Often gluten-free products have very little nutrition and fiber, it’s a bad idea to miss out on those!

What Is Gluten?

Gluten is a protein that is present in certain grains. Those grains are for example wheat, barley, rye, and spelt. The gluten protein ‘alfagliadine’ is toxic for people with celiac disease and the body starts an immune response. This causes the intestinal lining to get inflamed and this reduces your microvilli. Your microvilli are important for absorbing nutrients and having a healthy gut.

Celiac disease is estimated to affect 1,4% of the people worldwide. For all other people, gluten is not toxic. But people with Irritable Bowel Syndrome (IBS) can still react to it. Thankfully this will not destroy your microvilli, as it does in celiac disease. But it does cause a lot of inconvenience.
This can also be referred to as Non-Celiac Gluten Sensitivity (NCGS). It is still unsure whether NGCS is different from the fructan intolerance in the FODMAP diet.
The prevalence of NCGS is not known since there are also a lot of people who self diagnose it. But it is estimated around 6-12% of the people in Western countries.

This image from Atassi et al. in Nutrients in 2017 shows different triggers in wheat

Other than gluten, the FODMAP content, Agglutinin (another protein) and amylase trypsin inhibitors could play a role in triggering symptoms.

Signs of Gluten Sensitivity

The signs of celiac disease and NCGS differ a little (and overlap a lot), I will list both of them separately.

Celiac disease usually shows itself after the first introduction to gluten in early childhood. But it can actually go undetected up until after one’s thirties. In 10% of the cases, other members of the family also suffer from celiac disease.

NCGS can show itself at any age and is usually the result of food sensitivities or a disturbance in the gut like food poisoning, IBS or antibiotic use. Once your gut is out of balance, it can start to show symptoms.

NCGSCeliac Disease (12)
Stomach achesStomach aches
ConstipationReduced Microvili resulting in reduced nutrient absorption, and in the long run malnutrition.
HeadacheWeight Loss
AnxietyLoss of Appetite
Difficulty focusingGrowth Abnormalities
Nutrient Deficiencies Like Iron or B11 (Folic Acid)
Reduced Bone Density
Skin Conditions Like Dermatitis Herpetiformis or dry skin

Good news though. In most cases, a gluten-free diet will reduce the symptoms and can even reverse the damage that has been done to the microvilli in the gut.

Other than gluten, a common food allergy is a wheat allergy. It can be hard to distinguish between gluten and wheat allergies. But if you can eat rye bread without getting symptoms, and not regular bread, chances are it’s not the gluten you’re looking for.

This table from the article of Igbinedion SO et al. Non-celiac gluten sensitivity. Shows the overlap and differences between NCGS, Celiac Disease (CD), Irritable Bowel Syndrome (IBS) and Wheat Allergy (WA)

How To Diagnose Celiac Disease and NCGS?

Celiac disease is always diagnosed in a hospital. Since celiac disease is an immune response, there are antibodies to be found in your blood. This is usually the first thing a doctor checks once you come in with symptoms. If blood tests show antibodies to gluten in your blood, they will usually do a biopt (take a small piece) from your intestine to examine whether or not you have reduced microvilli. If you do, they will state the diagnosis. This is the most reliable way to diagnose celiac disease.

If you want NCGS to be diagnosed or determine whether you have a sensitivity to gluten, it becomes way harder to get a diagnosis. There are no reliable ways to do this, and it is usually done by the exclusion of celiac disease. If it’s evident you’re getting symptoms from gluten, but no signs of celiac disease are there, then it’s probably NCGS.

To actually test if you are responding to a certain food, you can do an elimination – introduction diet, like the one I describe in my FODMAP article. In short: you eliminate all gluten from your diet for 4 weeks and evaluate your symptoms.
If there’s no change, there’s little chance it’s gluten.
Are they gone/less? You start to try small amounts of gluten, to see if your symptoms come back. If so, you’re likely to respond to gluten.

Have you got celiac disease or gluten intolerance and would you like guidance from a dietitian who specializes in gut health? Then schedule an online consultation at my online dietician’s practice Darm diĆ«tist, and I will help you with all your questions!

The Treatment For Celiac Disease And NCGS

If you have celiac disease it is essential to eliminate gluten from your diet completely. If you do this right, your intestinal lining will heal itself in 2 – 5 years. In most cases, even the smallest crumb can trigger your symptoms and damage your intestinal lining. If a person with celiac disease keeps eating gluten, the damage of the intestine can (after years) even cause cancer in the intestine. The avoidance of gluten will, unfortunately, be a lifelong sentence, celiac disease is not something that can be solved at this moment.

NCGS, on the other hand, is not as dangerous (but still has very serious symptoms). To reduce your symptoms it is wise to eliminate gluten. If you do eat gluten though, your symptoms will come back, but there will be no serious effects of damage to your body like what is happening with celiac disease.

How To Replace Gluten?

When eating gluten-free, it is essential to find good and nutritious replacements for gluten-containing foods. And it’s wise to seek help from a specialized dietitian in this journey.

The main source of gluten in our food is bread, cereal, and pasta. Gluten is the main reason that your bread is nice and ‘fluffy’. It gives structure to your bread, binds water and makes sure it stays light and airy. Once the gluten is not present, the bread will be very compact and dense.
It is not that easy to create a tasty gluten-free bread (or other product). A lot of the time, the gluten-containing grains are being replaced by either potato, corn, soy or rice flour and loads of additives. All of which hardly have any nutritional value. Often extra fiber is added, to make up for the loss of fiber with the gluten-free substitutes.

Most people that have to eat gluten-free, have actually tasted gluten-containing bread. This makes the difference between the gluten-free and gluten-containing bread very clear. And often the search for a tasty gluten-free bread begins.

Gluten ContainingGluten Free
BarleyBuckwheat (Is often contaminated with gluten through production according to the Dutch Celiac Society, do look for the gluten-free brands!)
BeerOats (Are often contaminated with gluten through production, do look for the gluten-free brands!)
Cookies, cakes or pastriesAmaranth
Sauces and condimentsTeff
All products made from the above grains.
Such as pasta, gnocchi, couscous, noodles, pizza, bread
All other non-grain products like fruit, vegetables, nuts, seeds, meat, seafood, eggs, cheese, dairy, legumes.

The Gluten-free Label

Gluten free halm
The label usually contains an image resembling this picture.

When buying packaged products, it is wise to always check the ingredients to see if there aren’t any ‘hidden’ gluten in there.

If a product contains gluten, it has to be listed on the package. Products containing a ‘gluten-free’ label, usually shown as a grain with a cross through it, are tested and confirmed gluten-free. There is a threshold of the amount of gluten that these products can contain at a maximum. This threshold is 20 parts per million. These can either be products that had their gluten concentration reduced or natural gluten-free products.

Unfortunately, following a gluten-free diet is not cheap. Gluten-free products are reported to be 200 – 500% more expensive than their gluten-containing counterparts.

The Nutritional Challenges Of A Gluten-Free Diet

As mentioned before, gluten-free products usually consist of a combination of corn, rice, soy, cassava and potato. These ingredients have to replace gluten-containing grains. But as you can see in the 2 images below, it really depends on the gluten-free substitute you use, whether the product will have fiber (voedingsvezel in the table) or good amounts of vitamins. And it actually has been shown that people following a gluten-free diet have lower vitamin intake.

Especially if you would be making your own gluten-free products, try to use as many highly nutritious gluten-free ingredients as you can. And try to avoid the cheap and easy potato, corn and rice what the industry is often using.

Gluten containing and glutenfree grains
Screenshot from NEVO-Online showing the nutritional value of some gluten-containing and gluten-free products. The products with a red cross contain gluten.

If you use buckwheat, brown rice, oats (check for the gluten-free label!!) or quinoa, you have found yourself a great and nutritious gluten-free food. Substitutes like corn, white rice, potato starch, and soy are much less valuable based on their nutritional value. Choose your products wisely!

Gluten containing and glutenfree grains vitamins
Screenshot from NEVO-Online showing the vitamin values of some gluten-containing and gluten-free products.
The products with a red cross contain gluten.

Because there is also the problem with the elasticity and moisture of the gluten-free products, most of the gluten-free products are higher in fat (almost 2x more), sugar and sodium. To create a similar taste and structure to gluten-containing products. So for me, this shows that following a gluten-free diet should be well thought out. For the nutritional value of the diet, it is wise to seek advice from a dietitian.

Gluten and Weight Loss

If you want to follow the gluten-free diet for weight loss, I strongly advise you against that. There is no evidence that a gluten-free dietary pattern would promote weight loss, there have been studies that looked into it.

Celiac people or people with an NCGS would sooner gain weight on a gluten-free diet than lose weight if they have been properly educated about gluten-free foods. Since the gluten-free diet is majorly reducing their symptoms, and thus bringing the appetite back!

Gluten-Free Food Preparation

When handling gluten-free foods, or making food for someone that has celiac disease. It is of great importance to work clean, and not let their food be contaminated with gluten. Since, as mentioned above, the smallest crumble of gluten-containing foods can trigger their symptoms.

Make sure to always use a separate work area when preparing gluten-free foods, or just start with the gluten-free foods before handling gluten-containing foods. Have clean hands and kitchen utensils. If you want to use a toaster for example that has toasted gluten-containing bread, there are special bags (like these on Amazon) to put the gluten-free bread in to keep it safe.

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