Non-coeliac gluten sensitivity ( NCGS) | Research Level

Nothing beats feeling well.

Perhaps the one driving force behind my work is that nothing beats feeling well.

One of the things I am most often asked about by students who tell me that they can eat sourdough with no ill effects is why they feel unwell when eating fast fermented Chorleywood processed bread; one possibility is that they might have non-coeliac gluten sensitivity (NCGS)

There are many reasons that people find that sourdough is easier to digest and certainly the transformation of flour during the fermentation process potentially makes sourdough bread more nutritious and nourishing than yeasted bread  – it is a key area of my research, however in this article I want to focus on non-coeliac gluten sensitivity (NCGS)

WHAT IS NCGS?

Non-coeliac gluten sensitivity is a clinical manifestation, (meaning people present with a spectrum of signs and symptoms that vary in severity from person to person, and within the same person over time.)

These symptoms are induced by the ingestion of gluten leading to changes that improve once the gluten-containing food is removed from the diet. The sensitivity can cause many different symptoms including headaches, joint and muscle pain, foggy brain, nausea, abdominal pain, diarrhoea and constipation; and many more.

The prevalence of non-coeliac gluten sensitivity has estimated to be approximately 6% of the population. Unlike wheat allergy and coeliac disease, gluten sensitivity does not have a recognised set of biomarkers.  Doctors simply can’t tell if someone is suffering from it by examination (although there are blood tests, they don’t give accurate results for many patients). So this sensitivity can only be diagnosed by first ruling out other diseases and then trying a gluten-free diet. Until recently it was thought that the symptoms of non-coeliac gluten sensitivity were the only factor and people did not have any intestinal damage. However, in July 2016, a team of researchers at Columbia University Medical Centre, published a study that confirmed wheat exposure in this group was indeed triggering a systemic immune reaction and accompanying intestinal cell damage.

I AM NOT A DOCTOR

One thing I quickly realised when I began teaching the Nutrition and Digestibility of Bread  Diploma is that it’s a very sensitive area. Not least because any advice I give regarding bread and digestion could be considered to be medical advice. I’m not a doctor. I’m a baker with a specialism in understanding nutrition and digestion of bread, so I don’t give medical advice. This is something I make very clear to my students. What I can do is provide people with help in finding information, and I recommend they find out as much as they can, and then speak to their own doctor.

So any medical advice we share at The Sourdough School was to be given by our in-house GP.  We have Dr Alex Davidson

Dr Davison is an NHS GP with an interest in functional medicine. I think it’s very important any medical advice comes from our GP, because many of our students and the people who contact us with self-diagnosed gluten sensitivity find there are more layers of complexity to their condition, layers which go far beyond being simply an issue with digesting gluten.

OUR ADVISE

Alex’s advice is as follows –

“It is important not to make a self-diagnosis of gluten sensitivity and for people who are having digestive issues to visit their GP. Self-diagnosis can mean people miss other more serious medical conditions that a trained medical professional would pick up on. However, there are things that you can prepare and research before you visit your doctor that will help them to help you.

Non-coeliac gluten sensitivity was initially identified by Dr Alessio Fasano. It is an area that still isn’t mainstream medicine and not yet widely recognised. If you visit your doctor to talk about non-coeliac gluten sensitivity, you may find that they are not up to date with early research development. It’s a field in the very early stages of research, and it may well be you are introducing your doctor to the concept for the first time.

One thing you can do to help with a diagnosis is to keep a food diary. It is important that your food diary includes both physical and mental symptoms – things like mood, headaches, joint pains, tiredness, a foggy head, bloating, digestive issues and a description of your bowel movements. It’s essential for a doctor to have a complete overview of your symptoms before they can begin assessing which tests you might need. You might want to ask your doctor for a coeliac test. This is a widely recognised test which can be the starting place for your doctor to look at gluten issues and sensitivities. It’s also important to have enough time with your doctor to assess your symptoms, because when it comes to digestion issues it is often more complex than it seems at first, so you might want to book a double appointment. There can be other issues that manifest themselves with what at first looks like gluten sensitivity. Your doctor will need to consider these other illnesses and underlying causes because they could be at the root of your gluten sensitivities or issues.”

With Alex as our doctor, and having taught the RCGP accredited course in nutrition and digestibility of bread, I have a good insight into the frustration of trying to diagnose digestive issues and some of the pressure our NHS doctors have to work under. I also have students contact me suspecting that they have gluten sensitivity who tell me they feel their doctor is either not taking on board their symptoms, or has run out of tests available to them. My advice in this situation.

• Ask your patient to keep a food & mood diary as outlined above.
• Be patient For the person in front of you feeling unwell the feeling are very real and digestion is complex and it takes time to diagnose issues.
• Ask them to be open-minded. It might not even be gluten that they have an issue with.
• Discuss with different doctor in the same practice  – you might have a better outcome  – sometimes if someone new considers symptoms as they have a fresh perspective.

If you have exhausted all options then something to consider in this situation is having a further consultation and more tests done privately. Of course, in an ideal situation we would all be up to with the latest research and had a budget for the full range of tests. Unfortunately, this is not the situation and many NHS doctors are under an extreme amount of pressure, with just a short time to spend with each patient and a limited budget.

PRIVATE TESTS
Some of the tests that a private GP might be able to offer relating to gut function are as follows though please note that Biological systems medicine looks at many other roots of illness, not only the gut.

Some tests offer a deeper insight, whether these relate to detoxification issues, chronic underlying infections; mitochondrial problems; metals and other major chemicals that harm the body, genetics, nutritional deficiencies and so the list goes on. These are some of the tests that you might consider:

SIBO Lactulose

This test assists in the diagnosis and care for patients suffering from SIBO and Lactose, Fructose, Sucrose intolerance using lactulose as the substrate. The breath collection device included in the kits ensures accurate measuring of alveolar air and not room air, thus guarding against potential false negatives associated with other breath collection processes. Within 72 hours the lab will provide a detailed report with the information you need to make critical treatment decisions, traditionally this would take 2-3 weeks.

 Advanced Intestinal Barrier Assessment (AIBA)

Looks at 4 Measured Biomarkers:
Zonulin is a protein that regulates tight gap junctions in the gastrointestinal tract and modulates intestinal permeability. Increased levels of Zonulin can also be demonstrated in diseases associated with increased intestinal inflammation, such as celiac disease and type 1 diabetes. Its level relates to aspects such as gluten and the presence of infections.

Diamine oxidase (DAO) is the body’s primary enzyme for breaking down ingested histamine and a natural defence against histamine excess. If you ingest too much dietary histamine or produce more than your DAO level can handle, reactions can occur. DAO is produced in the small intestine but certain drugs, foods and bacteria may suppress its production, as can poor adrenal reserve.

Histamine is involved in many types of allergic and inflammatory processes, including immediate and delayed hypersensitivity reactions. Histamine imbalances in the body may cause a variety of adverse effects ranging from life-threatening allergic reactions to localised itching, runny nose or hives. Testing histamine along with diamine oxidase (DAO) levels provides important information that standard food sensitivity tests may not reveal. Histamine is also considered to be a neurotransmitter and is partly regulated by a process called methylation.

LPS The lipopolysaccharide (LPS) reflects bacterial products and a high level indicates intestinal permeability or leaky gut. When lipopolysaccharides are high in the blood, it means they are passing not only between intestinal cells but also directly through the cells, potentially causing neuroinflammation and brain injury. When LPS is absorbed into systemic circulation it can elicit a strong immune response.

Helicobacter Pylori

Helicobacter pylori has been evolving with human beings for well over 50,000 years H. pylori colonization has been implicated in a variety of gastroduodenal diseases including gastritis, gastric cancer, and duodenal and peptic ulcer. H. pylori have also been detected by stool PCR in cases of dyspepsia, abdominal pain, and chronic gastrointestinal symptoms.

CNS 200+ Allergy Test

The CNS FoodPrint® 200+ service utilises a new, state of the art immunoassay based on microarray technology to detect food-specific IgG antibodies. This gives you a colour coded print out of over 200 foods and food groups that you may show intolerance to leading to dietary changes, some of them temporary and others permanent.

GI Map

The GI-MAP is the first and only gut test in the world to be running full quantitative PCR (qPCR) on multiple GI targets, including pathogens, bacteria, worms, yeasts, parasites and comprehensive antibiotic-resistant genes, alongside intestinal health and immune markers.

The GI-MAP was designed to assess a patient’s microbiome from a single stool sample, with particular attention to microbes that cause disease or that disrupt normal microbial balance and contribute to perturbations in the GI flora and contribute to illness. With full quantification, we can now see the level of infection thus, the GI-MAP arms the clinician with accurate, actionable clinical information.

ONE (Optimal Nutritional Evaluation) FMV

Helps to give an understanding of individual diet and supplementation needs, and offers a personalized functional nutrition assessment covering antioxidants, B Vitamins, Digestive Support and Minerals. It is a group of 80-90 tests and the results are extremely helpful in identifying functional nutritional deficiencies.

Further reading

Skodje et al (2017) Fructan, rather than gluten, induces symptoms in patients with self-reported non-celiac gluten sensitivity.

Scherf, Koehler & Wieser (2016) Gluten and wheat sensitivities – an overview.

Sapone et al (2011) Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity.

Catassi et at (2013) Non-celiac gluten sensitivity: the new frontier of gluten-related disorders.

Makharia, Catassi & Makharia (2015) The overlap between irritable bowel syndrome and non-celiac gluten sensitivity: a clinical dilemma.