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Gluten intolerance or allergy is sensitivity to gluten, a substance found in staple foods such as wheat and barley. Gluten provides elasticity to dough and also helps the dough to rise. Major disorders related to gluten sensitivity include celiac disease (CD) and non-celiac gluten sensitivity. Gluten-related disorders are on the rise across the globe.
Symptoms related to gluten sensitivity vary widely. Symptoms at infancy include failure to thrive, developmental delay, abdominal distention, and sometimes, severe malnutrition. Beyond childhood, gluten allergy can manifest as gastrointestinal problems such as diarrhea, constipation, stomatitis, bloating, belching and other symptoms such as fatigue, joint pain, dyspepsia, anemia, weight loss, and depression.
Celiac disease is also known as gluten-sensitive enteropathy and is an autoimmune inflammatory disease affecting the small intestine. Studies show that about 1 in 250 people in the US suffer from CD. A diet free of gluten has been shown to reverse most of the effects of this disease. Patients are serologically tested for antibodies against transglutaminase, endomysium, and gliadin.
‘Silent’ CD with very few or no symptoms is also common. Many patients who were identified as having CD in seroprevalence studies did not show any symptoms of the disease. However, asymptomatic patients are at equal risk of for complications related to celiac disease. Therefore, people with a family history of gluten-sensitive enteropathy are at a genetic risk for CD and need to be tested.
Timely diagnosis and treatment of CD is crucial to prevent grave consequences such as osteoporosis and even cancer. CD is almost always associated with anemia. About 50% of patients with gluten-sensitive enteropathy are found to be anemic. Iron malabsorption is very common in people with CD as iron is normally absorbed in the proximal small intestine. Folate and vitamin B12 deficiency can also be present, but are less common.
Dermatitis herpetiformis affects less than 10 percent of adults with CD. It is a skin condition which is often misdiagnosed as nonspecific dermatitis or atypical psoriasis. Dermatitis herpetiformis causes intensely pruritic rashes and is typically seen in the back, elbows, and knees. Lesions look similar to those of herpes simplex and therefore the name “herpetiformis”. Skin biopsy is the common diagnostic tool used to detect dermatitis herpetiformis.
Non celiac gluten sensitivity (NCGS) is a disorder with intestinal and extra-intestinal symptoms following gluten ingestion in people with no CD or wheat allergy. Studies show that NCGS is usually associated with neuropsychiatric disorders such as autism and schizophrenia. About 18 million Americans have been estimated to have non-celiac gluten sensitivity. Due to lack of biomarkers for clinical studies, NCGS is still not fully differentiated from other disorders related to gluten intolerance.
A gluten-free diet aims to avoid foods made of or containing wheat, rye, and barley, and their derivatives including brewer’s yeast and malt. Safe substitutes are rice, maize, quinoa, corn, potato, tapioca, beans, and nuts. Many gluten-free products are commercially available and these include breads, chips, cookies, and cereals. Support groups exist to provide valuable information about gluten-free food products.
People on a gluten-free diet can still eat healthily by having normal amounts of vegetables, fruits, meats, fish, nuts, and beans. They can also switch to a range of alternatives such as amaranth, buckwheat, cornstarch, pea flour, millets, potato flour, and soy flour. However, all these grains are often grown and milled in nearby areas and are at high risk of cross-contact. Even minute amounts can be dangerous to the small intestine of people with a high degree of gluten allergy.
Although oats do not contain gluten in its natural form, there can be traces of gluten in commercially available oats due to cross contact. Therefore gluten-sensitive people should apply caution before using oats.