Gluten-related disorders: Difference between revisions

{{about-distinguish2distinguish-text|disorders related to [[gluten]], a natural ingredient in many cereals|sensitivities related to [[Glutamate flavoring|glutamate]], a flavor-enhancing additive}}

'''Gluten-related disorders''' is the term for the diseases triggered by [[gluten]], including [[celiac disease]] (CD), [[non-celiac gluten sensitivity]] (NCGS), [[gluten ataxia]], [[dermatitis herpetiformis]] (DH) and [[wheat allergy]].<ref name="pmid22345659">{{cite journal |vauthors=Ludvigsson JF, Leffler DA, Bai JC, Biagi F, Fasano A, Green PH, Hadjivassiliou M, Kaukinen K, Kelly CP, Leonard JN, Lundin KE, Murray JA, Sanders DS, Walker MM, Zingone F, Ciacci C |title=The Oslo definitions for coeliac disease and related terms |journal=Gut |volume=62 |issue=1 |pages=43–52 | date=January 2013 |pmid=22345659 |pmc=3440559 |doi=10.1136/gutjnl-2011-301346 |url=}}</ref><ref name="sapone-etal-2010-b" /> The umbrella category has also been referred to as '''gluten intolerance''', though a multi-disciplinary physician-led study, based in part on the 2011 International Coeliac Disease Symposium, concluded that the use of this term should be avoided due to a lack of specificity.<ref name="pmid22345659" />

[[Gluten]] is a group of [[protein]]s, such as [[prolamin]]s and [[glutelin]]s,<ref name=FDAlabeling2007>{{cite web |url=https://www.fda.gov/OHRMS/DOCKETS/98fr/05n-0279-npr0001.pdf|title= Food Labeling ; Gluten-Free Labeling of Foods |date= January 2007 |author= Food and Drug Administration |website= [[Food and Drug Administration]] |archive-url= https://web.archive.org/web/20070126011901/https://www.fda.gov/OHRMS/DOCKETS/98fr/05n-0279-npr0001.pdf |archive-date= 2007-01-26 }}</ref> stored with [[starch]] in the [[endosperm]] of various [[cereal|cereal (grass) grains]].

{{As of|2017}}, gluten-related disorders were increasing in frequency in different geographic areas. The increase might be explained by the popularity of the [[Western diet]], the expanded reach of the [[Mediterranean diet]] (which also includes grains with gluten), the growing replacement of rice by wheat in many countries,<ref name=TovoliMasi>{{cite journal | vauthors = Tovoli F, Masi C, Guidetti E, Negrini G, Paterini P, Bolondi L| title = Clinical and diagnostic aspects of gluten related disorders| journal = World J Clin Cases| volume = 3| issue = 3| pages = 275–84| date = March 16, 2015| pmid = 25789300|pmc= 4360499| doi = 10.12998/wjcc.v3.i3.275| doi-access = free}}</ref> the development in recent years of new types of wheat with a higher amount of [[Cytotoxicity|cytotoxic]] gluten [[peptide]]s,<ref name="VoltaCaioQuestions" /> and the higher content of gluten in bread and bakery products, due to the reduction of dough [[fermentation]] time.<ref name="VoltaCaioQuestions" /> However, a 2020 study by the Leibniz-Institute for Food Systems Biology casts doubt on the idea that modern wheat has higher gluten levels. From a seed bank, they grew and analyzed 60 wheat cultivars from between 1891 and 2010 and found no changes in albumin/globulin and gluten contents over time. "Overall, the harvest year had a more significant effect on protein composition than the cultivar. At the protein level, we found no evidence to support an increased immunostimulatory potential of modern winter wheat."<ref name = Scherf>{{cite journal |last1=Pronin |first1=Darina |last2=Borner |first2=Andreas |last3=Weber |first3=Hans |last4=Scherf |first4=Ann |title=Wheat (Triticum aestivum L.) Breeding from 1891 to 2010 Contributed to Increasing Yield and Glutenin Contents but Decreasing Protein and Gliadin Contents |journal=Journal of Agricultural and Food Chemistry |date=10 July 2020 |volume=68 |issue=46 |pages=13247–13256 |doi=10.1021/acs.jafc.0c02815|pmid=32648759 |s2cid=220469138 }}</ref>

The following classification of gluten-related disorders was announced in 2011 by a panel of experts in London, and published in February 2012:<ref>{{cite journal|last1=Sapone|first1=Anna|display-authors=etal|title=Spectrum of gluten-relate disorders: consensus on new nomenclature and classification|journal=BMC Medicine|date=7 February 2012|volume=2012|issue=10:13|pages=13|doi=10.1186/1741-7015-10-13|pmid=22313950|pmc=3292448 |doi-access=free }}</ref><ref name="Czaja-Bulsa-2014-section9-figure2">{{cite journal |author=Czaja-Bulsa G |title=Non coeliac gluten sensitivity - A new disease with gluten intolerance |journal=Clinical Nutrition (Edinburgh, Scotland) |volume= 34|issue= 2|pages= 189–194| date=August 2014 |pmid=25245857 |doi=10.1016/j.clnu.2014.08.012 |type=Review|doi-access=free }} See section 9 and Figure 2: Classification of gluten-dependent disorders.</ref>

[[Autoimmunity|Autoimmune]] conditions related to gluten include [[celiac disease]], [[dermatitis herpetiformis]], and [[gluten ataxia]]. There is research showing that in people with [[gluten ataxia]] early diagnosis and treatment with a gluten-free diet can improve ataxia and prevent its progression.<ref>{{cite journal |vauthors=Hadjivassiliou M, Sanders DS, Woodroofe N, Williamson C, Grünewald RA |s2cid=13427708 |title=Gluten ataxia |journal=Cerebellum |volume=7 |issue=3 |pages=494–8 |year=2008 |pmid=18787912 |doi=10.1007/s12311-008-0052-x |type=Review}}</ref> The population of people with gluten ataxia and other neurological conditions appears to have a different HLA distribution, in particular more [[HLA-DQ1]], compared to most persons with celiac disease, who have [[HLA-DQ2]] and [[HLA-DQ8]].<ref>{{cite journal |vauthors=Troncone R, Jabri B |title=Coeliac disease and gluten sensitivity |journal=Journal of Internal Medicine |volume=269 |issue=6 |pages=582–90 | date=June 2011 |pmid=21481018 |doi=10.1111/j.1365-2796.2011.02385.x |type=Review|doi-access=free }}</ref>

[[Coeliac disease]] ([[American and British English spelling differences|American English]]: celiac) (CD) is one of the most common chronic, immune-mediated disorders, triggered by the eating of [[gluten]], a mixture of proteins found in [[wheat]], [[barley]], [[rye]], and [[oats]] and derivatives.<ref name=Biesiekierski2017>{{cite journal| author=Biesiekierski JR| s2cid=6493455 | title=What is gluten? | journal=J Gastroenterol Hepatol | year= 2017 | volume= 32 | issue=Suppl 1 | pages= 78–81 | pmid=28244676 | doi=10.1111/jgh.13703 | type=Review | quote= Similar proteins to the gliadin found in wheat exist as secalin in rye, hordein in barley, and avenins in oats and are collectively referred to as “gluten.” The gluten found in all of these grains has been identified as the component capable of triggering the immune-mediated disorder, coeliac disease.| doi-access=free }}{{open access}}</ref><ref name=LebwoholLudvigsson /> Evidence has shown that this condition not only has an environmental component but a genetic one as well, due to strong associations of CD with the presence of HLA ([[Human leukocyte antigen]]) type II, specifically DQ2 and DQ8 alleles.<ref name=Denham>{{cite journal|last1=Denham|first1=JM|last2=Hill|first2=ID|title=Celiac disease and autoimmunity: review and controversies.|journal=Current Allergy and Asthma Reports|date=August 2013|volume=13|issue=4|pages=347–53|pmid=23681421|doi=10.1007/s11882-013-0352-1|pmc=3725235}}</ref> These alleles can stimulate a [[T&nbsp;cell]], mediated immune response against tissue [[transglutaminase]] (TTG), an enzyme in the extracellular matrix, leading to inflammation of the intestinal mucosa and eventually villous atrophy of the small intestine.<ref name=Pasha>{{cite journal|last1=Pasha|first1=I|last2=Saeed|first2=F|last3=Sultan|first3=MT|last4=Batool|first4=R|last5=Aziz|first5=M|last6=Ahmed|first6=W|s2cid=25585961|title=Wheat Allergy and Intolerence; Recent Updates and Perspectives.|journal=Critical Reviews in Food Science and Nutrition|date=2 January 2016|volume=56|issue=1|pages=13–24|pmid=24915366|doi=10.1080/10408398.2012.659818}}</ref> This is where the innate and adaptive immune response systems collide.

[[File:Inflammed mucous layer of the intestinal villi depicting Celiac disease.jpg|thumb|249x249px|Villous atrophy of the small intestine.]]

CD is not only a gastrointestinal disease. It may involve several organs and cause an extensive variety of non-gastrointestinal symptoms. Most importantly, it may often be completely asymptomatic. Added difficulties for diagnosis are the fact that [[serological]] markers ([[Anti-transglutaminase antibodies#Anti-tissue transglutaminase|anti-tissue transglutaminase]] [TG2]) are not always present<ref name=NEJM2012>{{cite journal|last1=Fasano|first1=A|last2=Catassi|first2=C|title=Clinical practice. Celiac disease.|journal=The New England Journal of Medicine|date=December 20, 2012|volume=367|issue=25|pages=2419–26|pmid=23252527|doi=10.1056/NEJMcp1113994}}</ref> and many people may have minor mucosal lesions, without atrophy of the [[intestinal villi]].<ref name=BoldRostami>{{cite journal | vauthors = Bold J, Rostami K| title = Gluten tolerance; potential challenges in treatment strategies | journal = Gastroenterol Hepatol Bed Bench | volume = 4| issue = 2| pages = 53–7| date = 2011 | pmid = 24834157|pmc= 4017406}}</ref> Diagnosis of CD should be based on a combination of person’sperson's familial history, genetics (i.e. presence of HLA DQ2/DQ8) serology and intestinal histology.<ref name=ElliBranchi />

CD affects approximately 1–2% of general population all over the world,<ref name=LundinWijmenga2015>{{cite journal|vauthors=Lundin KE, Wijmenga C|s2cid=24533103|title=Coeliac disease and autoimmune disease-genetic overlap and screening|journal=Nat Rev Gastroenterol Hepatol|volume=12|issue=9|pages=507–15|date =September 2015|pmid=26303674|doi=10.1038/nrgastro.2015.136}}</ref> but most cases remain unrecognized, undiagnosed and untreated, and exposed to the risk of long-term complications.<ref name="ElliBranchi" /><ref name="Fasano2005Pediatric">{{cite journal | author =Schuppan Fasano& Gisbert-Schuppan A|date=2019 |title =Wheat ClinicalSyndromes: presentationHow ofWheat, celiacGluten diseaseand inATI theCause pediatricInflammation, populationIBS |and journalAutoimmune Diseases |journal= GastroenterologyBook | volume = 128| issue = 4 Suppl 1| pages = S68–73| date doi= April 2005| pmid = 15825129 |pmcvia=Springer |Nature doiSwitzerland =AG, 10.1053/j.gastro.2005.02Switzerland.015}}</ref> People may sufferexperience severe disease symptoms and be subjected to extensive investigations for many years, before a proper diagnosis is achieved.<ref name=LudvigssonCard>{{cite journal | vauthors = Ludvigsson JF, Card T, Ciclitira PJ, Swift GL, Nasr I, Sanders DS, Ciacci C| title = Support for patients with celiac disease: A literature review | journal = United European Gastroenterol J | volume = 3 | issue = 2 | pages = 146–59 | date = April 2015 | pmid = 25922674 | pmc = 4406900 |doi = 10.1177/2050640614562599}}</ref> Untreated CD may result in the lack of absorption of nutrients, reduced quality of life, [[iron deficiency]], [[osteoporosis]], an increased risk of intestinal [[lymphoma]]s and greater mortality.<ref name=LebwoholLudvigsson /> CD is associated with some autoimmune diseases, such as [[diabetes mellitus type 1]],<ref name="Denham" /> [[thyroiditis]],<ref name=LundinWijmenga>{{cite journal | vauthors = Lundin KE, Wijmenga C| s2cid = 24533103| title = Coeliac disease and autoimmune disease-genetic overlap and screening| journal = Nat Rev Gastroenterol Hepatol| volume = 12| issue = 9| pages = 507–15| date = September 2015 | pmid = 26303674 | doi = 10.1038/nrgastro.2015.136}}</ref> [[ataxia|gluten ataxia]], [[psoriasis]], [[vitiligo]], [[autoimmune hepatitis]], [[dermatitis herpetiformis]], [[primary sclerosing cholangitis]], and more.<ref name=LundinWijmenga />

CD with "classic symptoms", which include gastrointestinal manifestations such as chronic diarrhea and bloating, malabsorption of certain vitamins and minerals, loss of appetite, impaired growth and even bone pain, is currently the least common presentation form of the disease and affects predominantly to small children generally younger than two years of age.<ref name="Pasha" /><ref name=Fasano2005Pediatric /><ref name=LudvigssonCard />

CD with "non-classic symptoms" is the most common clinical found type<ref name=LudvigssonCard /> and occurs in older children (over 2two years old),<ref name=LudvigssonCard /> adolescents and adults.<ref name=LudvigssonCard /> It is characterized by milder or even absent gastrointestinal symptoms and a wide spectrum of non-intestinal manifestations that can involve any organ of the body such as, [[cerebellar ataxia]], hypertransaminasemia and [[peripheral neuropathy]].<ref name="ElliBranchi" /> As previously mentioned, CD very frequently may be completely asymptomatic<ref name=Fasano2005Pediatric /> both in children (at least in 43% of the cases<ref name=VriezingaSchweizer>{{cite journal |vauthors=Vriezinga SL, Schweizer JJ, Koning F, Mearin ML |s2cid=2023530 |title=Coeliac disease and gluten-related disorders in childhood |journal=Nature Reviews. Gastroenterology & Hepatology |volume= 12 |issue= 9 |pages= 527–36 |date= Sep 2015 |pmid=26100369 |doi=10.1038/nrgastro.2015.98 |type=Review}}</ref>) and adults.<ref name=Fasano2005Pediatric />

To date, the only available medically accepted treatment for people with coeliac disease is to follow a lifelong gluten-free diet.<ref name="ElliBranchi" /><ref name="LamacchiaCamarca2014">{{cite journal |vauthors=Lamacchia C, Camarca A, Picascia S, Di Luccia A, Gianfrani C |title=Cereal-based gluten-free food: how to reconcile nutritional and technological properties of wheat proteins with safety for celiac disease patients |journal=Nutrients |volume=6 |issue=2 |pages=575–90 |year=2014 |pmid=24481131 |pmc=3942718 |doi=10.3390/nu6020575 |type=Review|doi-access=free }}</ref><ref name="De Palma">{{cite journal |last1=De Palma |first1=Giada De |last2=Nadal |first2=Inmaculada |last2last3=NadalCollado |first3=Maria Carmen |last3last4=ColladoSanz |first4=Yolanda |last4=Sanz|title=Effects of a gluten-free diet on gut microbiota and immune function in healthy adult human subjects |journal=British Journal of Nutrition |yeardate=2009 |volume=102 |issue=8 |pages=1154–1160 |doi= 10.1017/S0007114509371767 |pmid=19445821 |issues2cid=84537912 |urlhdl=https://digital.csic.es/bitstream/10261/15885/1/BJN |hdl-GFD.pdfaccess=free }}</ref>

[[Dermatitis herpetiformis]] (DH), or Duhring-Brocq disease, is a [[Chronic (medicine)|chronic]] [[blister]]ing [[Human skin|skin]] [[autoimmune disease|autoimmune]] condition, characterized by the presence of skin lesions that have an extensive and symmetrical distribution, predominating in areas of greater friction, and affecting mainly both elbows, knees, buttocks, ankles, and may also affect the scalp and other parts of the body, and non-symmetrical occasionally. The lesions are vesicular-crusted and when flake off, they evolve to pigmented areas or achromic an intense burning, itchy and blistering rash.<ref name=MulderWanrooij>{{cite journal | vauthors = Mulder CJ, van Wanrooij RL, Bakker SF, Wierdsma N, Bouma G | s2cid = 14124370 | title = Gluten-free diet in gluten-related disorders | journal = Dig. Dis. | volume = 31| issue = 1| pages = 57–62| date = 2013| pmid = 23797124|doi = 10.1159/000347180 |type= Review }}</ref><ref name=MendesHissaElian>{{cite journal | vauthors = Mendes FB, Hissa-Elian A, Abreu MA, Gonçalves VS| title = Review: dermatitis herpetiformis| journal = An Bras Dermatol| volume = 88| issue = 4| pages = 594–9| date = 2013 | pmid = 24068131|pmc= 3760935| doi = 10.1590/abd1806-4841.20131775 | type=Review}}</ref> Despite its name, DH is neither related to nor caused by [[herpesviridae|herpes virus]]: the name means that it is a skin inflammation having an appearance similar to [[herpes]].

The age of onset is variable starting in children and adolescence but can also affect individuals of both sexes indistinctly at any age of their lives.<ref name=MendesHissaElian /><ref name=AntigaCaproni>{{cite journal | vauthors = Antiga E, Caproni M | title = The diagnosis and treatment of dermatitis herpetiformis| journal = Clin Cosmet Investig Dermatol| volume = 8 | pages = 257–65 | date = May 13, 2015 | pmid = 25999753 |pmc= 4435051| doi = 10.2147/CCID.S69127| doi-access = free}}</ref>

[[File:Gluten ataxia eng.ogg|thumb|Gluten ataxia eng|A male with gluten ataxia: previous situation and evolution after three months of gluten-free diet]]

Early diagnosis and treatment with a [[gluten-free diet]] can improve ataxia and prevent its progression. The effectiveness of the treatment depends on the elapsed time from the onset of the ataxia until diagnosis, because the death of [[Purkinje cells|neurons in the cerebellum]] as a result of gluten exposure is irreversible.<ref name="HadjivassiliouSanders2015" /><ref name="MitomaAdhikari2016">{{cite journal| vauthors=Mitoma H, Adhikari K, Aeschlimann D, Chattopadhyay P, Hadjivassiliou M, Hampe CS et al.| title=Consensus Paper: Neuroimmune Mechanisms of Cerebellar Ataxias | journal=Cerebellum | year= 2016 | volume= 15 | issue= 2 | pages= 213–32 | pmid=25823827 | doi=10.1007/s12311-015-0664-x | pmc=4591117 | type=Review }} </ref>

Gluten ataxia accounts for 40% of ataxias of unknown origin and 15% of all ataxias.<ref name="HadjivassiliouSanders2015">{{cite journal| vauthors=Hadjivassiliou M, Sanders DD, Aeschlimann DP| s2cid=207673823 | title=Gluten-related disorders: gluten ataxia | journal=Dig Dis | year= 2015 | volume= 33 | issue= 2 | pages= 264–8 | pmid=25925933 | doi=10.1159/000369509 | type=Review }} </ref><ref name="pmid12566288">{{cite journal | vauthors = Hadjivassiliou M, Grünewald R, Sharrack B, Sanders D, Lobo A, Williamson C, Woodroofe N, Wood N, Davies-Jones A | title = Gluten ataxia in perspective: epidemiology, genetic susceptibility and clinical characteristics | journal = Brain | volume = 126 | issue = Pt 3 | pages = 685–91 | date = March 2003 | pmid = 12566288 | doi = 10.1093/brain/awg050 | doi-access = free }}</ref> Less than 10% of people with gluten ataxia present any gastrointestinal symptom, yet about 40% have intestinal damage.<ref name="HadjivassiliouSanders2015" />

Non-celiac gluten sensitivity (NCGS), or gluten sensitivity (GS)intolerance,<ref name="pmid22345659" /> is a syndrome in which people develop a variety of intestinal and/or extraintestinal symptoms that improve when [[gluten]] is removed from the diet,<ref name=ElliRoncorni>{{cite journal | vauthors = Elli L, Roncoroni L, Bardella MT| title = Non-celiac gluten sensitivity: Time for sifting the grain | journal = World J Gastroenterol | volume = 21| issue = 27| pages = 8221–6| date = July 2015 | pmid = 26217073 |pmc= 4507091 | doi = 10.3748/wjg.v21.i27.8221|type= Review | doi-access = free }}</ref> after [[coeliac disease]] and [[wheat allergy]] are excluded.<ref name="FasanoSapone2015" /> NCGS, which is possibly immune-mediated, now appears to be more common than coeliac disease,<ref name="Hogg-Collars-2014">{{cite journal |vauthors=Hogg-Kollars S, Al Dulaimi D, Tait K, Rostami K |title=Type 1 diabetes mellitus and gluten induced disorders |journal=Gastroenterology and Hepatology from Bed to Bench |volume=7 |issue=4 |pages=189–97 |year=2014 |pmid=25289132 |pmc=4185872 |doi= |type=Review}}</ref> with a prevalence estimated to be 6–10 times higher.<ref name=MolinaInfanteSantolaria>{{cite journal | vauthors = Molina-Infante J, Santolaria S, Montoro M, Esteve M, Fernández-Bañares F| title = [Non-celiac gluten sensitivity: a critical review of current evidence] [Article in Spanish] | journal = Gastroenterol Hepatol | volume = 37| issue = 6 | pages = 362–71 | date = 2014 | pmid = 24667093 | doi = 10.1016/j.gastrohep.2014.01.005}}</ref>

Gastrointestinal symptoms, which resemble those of [[irritable bowel syndrome]] (IBS),<ref name=ElliRoncorni /><ref name="CatassiBai2013">{{cite journal|vauthors=Catassi C, Bai J, Bonaz B, Bouma G, Calabrò A, Carroccio A, Castillejo G, Ciacci C, Cristofori F, Dolinsek J, Francavilla R, Elli L, Green P, Holtmeier W, Koehler P, Koletzko S, Meinhold C, Sanders D, Schumann M, Schuppan D, Ullrich R, Vécsei A, Volta U, Zevallos V, Sapone A, Fasano A|title=Non-celiac gluten sensitivity: the new frontier of gluten related disorders|journal=Nutrients|volume=5|issue=10|year=2013|pages=3839–3853|issn=2072-6643|doi=10.3390/nu5103839|pmid=24077239|type=Review|pmc=3820047|doi-access=free}}</ref> may include any of the following: [[abdominal pain]], [[bloating]], bowel habit abnormalities (either [[diarrhea]] or [[constipation]]),<ref name="CatassiBai2013" /><ref name=VoltaCaio2015>{{cite journal | vauthors = Volta U, Caio G, De Giorgio R, Henriksen C, Skodje G, Lundin KE| title = Non-celiac gluten sensitivity: a work-in-progress entity in the spectrum of wheat-related disorders | journal = Best Pract Res Clin Gastroenterol | volume = 29| issue = 3| pages = 477–91| date = June 2015| pmid = 26060112 | doi = 10.1016/j.bpg.2015.04.006}}</ref> [[nausea]], [[aerophagia]], [[gastroesophageal reflux disease]], and [[aphthous stomatitis]].<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" />

Extra-intestinal symptoms, which can be the only manifestation of NCGS even in absence of gastrointestinal symptoms, may be any of the following: [[headache]] or [[migraine]], “foggy"foggy mind”mind", [[fatigue (medical)|fatigue]],<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=VoltaCaio2015 /> [[fibromyalgia]],<ref name=VoltaCaio2015 /><ref name=RossiDiLollo>{{cite journal | vauthors = Rossi A, Di Lollo AC, Guzzo MP, Giacomelli C, Atzeni F, Bazzichi L, Di Franco M | title = Fibromyalgia and nutrition: what news? | journal = Clin Exp Rheumatol | volume = 33 | issue = 1 Suppl 88 | pages = S117–25 | date = 2015 | pmid = 25786053 | doi = }}</ref><ref name=SanMauroGaricano>{{cite journal | vauthors = San Mauro Martín I, Garicano Vilar E, Collado Yurrutia L, Ciudad Cabañas MJ | title = [Is gluten the great etiopathogenic agent of disease in the XXI century?] [Article in Spanish] |date = December 2014 |journal = Nutr Hosp |volume = 30 |issue = 6 | pages = 1203–10 | doi = 10.3305/nh.2014.30.6.7866 | pmid = 25433099}}</ref> joint and muscle pain,<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=VoltaCaio2015 /> leg or arm [[hypoesthesia|numbness]],<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=VoltaCaio2015 /> [[paresthesia|tingling]] of the extremities,<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> dermatitis ([[dermatitis|eczema]] or [[rash|skin rash]]),<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> [[atopy|atopic disorders]],<ref name=FasanoSapone2015 /> [[allergy]] to one or more inhalants, foods or metals<ref name=FasanoSapone2015 /><ref name=VoltaCaio2015 /> (such as [[mite]]s, [[poaceae|graminaceae]], [[parietaria]], cat or dog hair, [[shellfish]], or [[nickel]]),<ref name=VoltaCaio2015 /> [[depression (mood)|depression]],<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=VoltaCaio2015 /> [[anxiety]],<ref name=VoltaCaio2015 /> [[anemia]],<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> [[iron-deficiency anemia]], [[folate deficiency]], [[asthma]], [[rhinitis]], [[eating disorder]]s,<ref name=VoltaCaio2015 /> or [[autoimmune disease]]s.<ref name=FasanoSapone2015 />

Among extra-intestinal manifestations, NCGS seems to be involved in some [[neuropsychiatric disorder]]s,<ref>{{Cite journal|last1=Bressan|first1=Paola|last2=Kramer|first2=Peter|date=2016|title=Bread and Other Edible Agents of Mental Disease|journal=Frontiers in Human Neuroscience|language=Englishen|volume=10|pagespage=130|doi=10.5281/zenodo.1004705|pmid=27065833|pmc=4809873|doi-access=free}}</ref> principally [[schizophrenia]],<ref name=LebwoholLudvigsson>{{cite journal | vauthors =Lebwohl B, Ludvigsson JF, Green PH | title = Celiac disease and non-celiac gluten sensitivity | journal = BMJ | volume = 351 | pages = h4347| date = October 2015 | pmid = 26438584|pmc= 4596973 | doi = 10.1136/bmj.h4347|type= Review }}</ref><ref name="CatassiBai2013" /> [[autism]]<ref name=LebwoholLudvigsson /><ref name="CatassiBai2013" /><ref name=VoltaCaio2015 /> and [[peripheral neuropathy]],<ref name=LebwoholLudvigsson /><ref name="CatassiBai2013" /> and also [[ataxia]]<ref name=LebwoholLudvigsson /> and [[attention deficit hyperactivity disorder]] (ADHD).<ref name=FasanoSapone2015 />

Gluten is likely responsible for the appearance of symptoms, but it has been suggested than in a subgroup of people with NCGS and symptoms like IBS, other components of wheat and related grains (oligosaccharides like fructans), or other plant proteins contained in gluten-containing cereals (agglutinins, lectins, and [[amylase trypsin inhibitor]]s (ATIs)) may play a role in the development of gastrointestinal symptoms.<ref name=ElliBranchi>{{cite journal | vauthors = Elli L, Branchi F, Tomba C, Villalta D, Norsa L, Ferretti F, Roncoroni L, Bardella MT| title = Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity | journal = World J Gastroenterol | volume = 21 | issue = 23 | pages = 7110–9 | date = June 2015 | pmid = 26109797 |pmc= 4476872 | doi = 10.3748/wjg.v21.i23.7110 | doi-access = free }}</ref> ATIs are about 2–4% of the total protein in modern wheat and 80–90% in gluten.<ref name="FasanoSapone2015" /> In a review of May 2015 published in [[Gastroenterology (journal)|''Gastroenterology'']], [[Alessio Fasano|Fasano]] ''et al.'' conclude that ATIs may be the inducers of innate immunity in people with coeliac disease or NCGS.<ref name=FasanoSapone2015 /> As of 2019, reviews conclude that although FODMAPs[[FODMAP]]s present in wheat and related grains may play a role in non-celiac gluten sensitivity, they only explain certain gastrointestinal symptoms, such as [[bloating]], but not the [[non-celiac gluten sensitivity#Extraintestinal|extra-digestive symptoms]] that people with non-celiac gluten sensitivity may develop, such as [[neurological disorder]]s, [[fibromyalgia]], psychological disturbances, and [[dermatitis]].<ref name=Verbeke2018>{{cite journal |last1=Verbeke |first1=K |title=Nonceliac Gluten Sensitivity: What Is the Culprit? |journal=Gastroenterology |date=February 2018 |volume=154 |issue=3 |pages=471–473 |doi=10.1053/j.gastro.2018.01.013 |pmid=29337156| quote=Although intolerance to fructans and other FODMAPs may contribute to NCGS, they may only explain gastrointestinal symptoms and not the extraintestinal symptoms observed in NCGS patients, such as neurologic dysfunction, psychological disturbances, fibromyalgia, and skin rash.15 Therefore, it is unlikely that they are the sole cause of NCGS.|doi-access=free }}</ref><ref name=VoltaDeGiorgio2019>{{cite journal| vauthors=Volta U, De Giorgio R, Caio G, Uhde M, Manfredini R, Alaedini A| title=Nonceliac Wheat Sensitivity: An Immune-Mediated Condition with Systemic Manifestations | journal=Gastroenterol Clin North Am | date= March 2019 | volume= 48 | issue= 1 | pages= 165–182 | pmid=30711208 | doi=10.1016/j.gtc.2018.09.012 | pmc=6364564 | type=Review |quote=Furthermore, a role for the FODMAP (eg, fructans) component of wheat as the sole trigger for symptoms is somewhat doubtful, because many patients with NCWS report resolution of symptoms after the withdrawal of wheat and related cereals, while continuing to ingest vegetables and fruits with high FODMAP content in their diets.59 On the whole, it is conceivable that more than one culprit may be involved in symptoms of NCWS (as they are currently defined), including gluten, other wheat proteins, and FODMAPs.60–62 }} </ref><ref name="FasanoSapone2015" /> As occurs in people with coeliac disease, the treatment is a [[gluten-free diet]] (GFD) strict and maintained, without making any dietary transgression.<ref name=VoltaCaio2015 /> Whereas coeliac disease requires adherence to a strict lifelong gluten-free diet, it is not yet known whether NCGS is a permanent, or a transient condition.<ref name=VriezingaSchweizer /><ref name=VoltaCaio2015 /> The results of a 2017 study suggest that NCGS may be a chronic disorder, as is the case with celiac disease.<ref name=VoltaDeGiorgio2019 /> Theoretically, a trial of gluten reintroduction to observe reaction after 1–2 years of strict gluten-free diet might be advisable.<ref name=VoltaCaio2015 />

Approximately one -third of personaspersons with NCGS continue having symptoms despite gluten withdrawal. This may be due to diagnostic error, poor dietary compliance, or other reasons. Those afflicted with NCGS may be under the impression that they don'tdo not need to follow a strictly [[gluten free diet]]. However, the ingestion of even a small amount of gluten may cause more immediate symptoms in people suffering fromwith NCGS as compared with those afflicted with coeliac disease. People with NCGS should carefully read ingredient labels on food and be aware of potential [[cross contamination]] as a source of gluten in otherwise gluten-free foods. To find out if there are unintended ingestions of gluten, an exhaustive evaluation with the advice of a coeliac disease specialized dietitian could be necessary.<ref name=VoltaCaio2015 />

In some cases, people can significantly improve with a low [[FODMAP]]sFODMAPs diet in addition to gluten withdrawal<ref name="VoltaCaioQuestions" /> and/or a GFD with a low content of preservatives and additives.<ref name="VoltaCaioQuestionsQuotation">{{cite journal|vauthors=Volta U, Caio G, Tovoli F, De Giorgio R|title=Non-celiac gluten sensitivity: questions still to be answered despite increasing awareness|journal=Cellular and Molecular Immunology|volume=10|issue=5|year=2013|pages=383–392|issn=1672-7681|doi=10.1038/cmi.2013.28|pmid=23934026|type=Review|pmc=4003198}}</ref> Furthermore, associated to gluten sensitivity, NCGS people may often present IgE-mediated [[allergy|allergies]] to one or more foods<ref name=VoltaCaio2015 /> and it is estimated that around 35% of people sufferwith some [[food intolerance]]s, mainly [[lactose intolerance]].<ref name=AzizHadjivassiliou2015>{{cite journal | vauthors = Aziz I, Hadjivassiliou M, Sanders DS | s2cid = 2867448 | title = The spectrum of noncoeliac gluten sensitivity | journal = Nat Rev Gastroenterol Hepatol | volume = 12| issue = 9| pages = 516–26| date = September 2015| pmid = 26122473 | doi = 10.1038/nrgastro.2015.107 | type= Review }}</ref>

People can also experience adverse effects of wheat as result of a [[wheat allergy]].<ref name=ElliBranchi /> Gastrointestinal symptoms of wheat allergy are similar to those of coeliac disease and non-celiac gluten sensitivity, but there is a different interval between exposure to wheat and onset of symptoms. Wheat allergy has a fast onset (from minutes to hours) after the consumption of food containing wheat and could be [[anaphylaxis]].<ref name=NEJM2012 /><ref name=ScherfBrockowQuotation>{{cite journal|vauthors=Scherf KA, Brockow K, Biedermann T, Koehler P, Wieser H|title=Wheat-Dependent Exercise-Induced Anaphylaxis|journal=Clin Exp Allergy [Epub ahead of print]|volume=46|issue=1|pages=10–20|date=September 18, 2015|pmid=26381478|doi =10.1111/cea.12640|s2cid=25066563}}</ref>

The treatment of wheat allergy consists of complete withdrawal of any food containing wheat and other gluten-containing cereals.<ref name=ScherfBrockowQuotation /><ref name=HischenhuberCrevelQuotation>{{cite journal |vauthors=Hischenhuber C, Crevel R, Jarry B, Mäki M, Moneret-Vautrin DA, Romano A, Troncone R, Ward R|title=Review article: safe amounts of gluten for patients with wheat allergy or coeliac disease |journal=Aliment Pharmacol Ther |volume=23|issue=5|pages=559–75|date=March 1, 2006|pmid =16480395|doi=10.1111/j.1365-2036.2006.02768.x|doi-access=free}}</ref> Nevertheless, some people can tolerate barley, rye or oats.<ref name=Pietzak>{{cite journal|author=Pietzak M|title=Celiac disease, wheat allergy, and gluten sensitivity: when gluten free is not a fad|journal=JPEN J Parenter EnteralEnter Nutr|volume=36|issue=1 Suppl|pages=68S–75S|date=Jan 2012|pmid=22237879|doi=10.1177/0148607111426276}}</ref>

=== Other conditions or risk factors ===

[[Anti-gliadin antibodies|Antibodies to α-gliadin]] have been significantly increased in non-celiacs individuals with [[oral ulceration]].<ref name="pmid1753350">{{cite journal |vauthors=O'Farrelly C, O'Mahony C, Graeme-Cook F, Feighery C, McCartan BE, Weir DG | author-link1 = Cliona O’Farrelly | title = Gliadin antibodies identify gluten-sensitive oral ulceration in the absence of villous atrophy | journal = J.Journal of Oral Pathol.Pathology Med.and Medicine | volume = 20 | issue = 10 | pages = 476–8 | year = 1991 | pmid = 1753350 | doi =10.1111/j.1600-0714.1991.tb00407.x }}</ref> Anti-α-gliadin antibodies are frequently found in celiac disease (CD), to a lesser degree [[wikt:subclinical|subclinical]] CD, but are also found in a subset who do not have the disease. Of people with [[pseudo-exfoliation syndrome]], 25% showed increased levels of anti-gliadin IgA.<ref name="pmid7656149">{{cite journal |vauthors=Ringvold A, Overgaard RG | title = Increased IgA antibodies to gluten and gliadin in serum of persons with ocular pseudo-exfoliation | journal = Acta Ophthalmologica Scandinavica | volume = 73 | issue = 2 | pages = 171–2 | year = 1995 | pmid = 7656149 | doi =10.1111/j.1600-0420.1995.tb00662.x | type=Comparative Study}}</ref> Other people that are also at risk are those taking gluten despite having the disorder, or whose family members have CD. In addition people with autoimmune conditions are also at risk for CD. It has just been found that there is a risk of death in CD. Therefore, gluten intake should be limited before or even after the diagnosis.<ref name="coeliac disease in children">{{Cite journal|date=2015-08-05|title=Coeliac disease in children|journal=Nursing Standard|volume=29|issue=49|pages=36–41|doi=10.7748/ns.29.49.36.e10022|pmid=26243121|issn=0029-6570|last1=Paul|first1=Siba Prosad|last2=Kirkham|first2=Emily Natasha|last3=Pidgeon|first3=Sarah|last4=Sandmann|first4=Sarah}}</ref> One -fourth of people with [[Sjögren's syndrome]] had responses to gluten,; of 5five that had positive response to gluten, only one could be confirmed as CD and another was potentially {{clarify|text=GSE|reason=Is GSE (gluten-sensitive enteropathy) meant to stand for coeliac disease, or for what else? see http://www.aafp.org/afp/2002/1215/p2259.html|date=December 2014}}, the remaining 3three appearappeared to be gluten-sensitive. All were HLA-DQ2 and/or DQ8-positive.<ref name="pmid17613926">{{cite journal |vauthors=Lidén M, Kristjánsson G, Valtýsdóttir S, Hällgren R | s2cid = 26333122 | title = Gluten sensitivity in patients with primary Sjögren's syndrome | journal = Scand. J. Gastroenterol. | volume = 42 | issue = 8 | pages = 962–7 | year = 2007 | pmid = 17613926 | doi = 10.1080/00365520701195345|type=Research Support, Non-U.S. Gov't}}</ref>

More than 250 symptoms of gluten sensitivity have been reported, including [[bloating]], abdominal discomfort or pain, constipation and diarrhea.<ref name="Korn">{{cite book|last=Korn|first=Danna|title=Living gluten-free for dummies|url=https://archive.org/details/livingglutenfree00korn|url-access=registration|location=Hoboken, NJ|publisher=Wiley Pub.|year=2006|pppages=[https://archive.org/details/livingglutenfree00korn/page/14 14], 27–31|isbn=9780471773832}}</ref> Sensitivity may also present with extraintestinal symptoms, including headache, "[[Brain Fog|brain fog]]", tingling and/or numbness in hands and feet, fatigue, as well as muscular disturbances and bone or joint pain;<ref name="sapone-etal-2010-a">{{cite journal |vauthors=Sapone A, Lammers KM, Mazzarella G, etal |title=Differential mucosal IL-17 expression in two gliadin-induced disorders: gluten sensitivity and the autoimmune enteropathy celiac disease |journal=Int. Arch. Allergy Immunol. |volume=152 |issue=1 |pages=75–80 |year=2010 |pmid=19940509 |pmc=2956008 |doi=10.1159/000260087 |type=Research Support, N.I.H., Extramural}}</ref><ref name="ReferenceB">{{cite journal |vauthors=Hadjivassiliou M, Chattopadhyay AK, Grünewald RA, etal |title=Myopathy associated with gluten sensitivity |journal=Muscle Nerve |volume=35 |issue=4 |pages=443–50 | date=April 2007 |pmid=17143894 |doi=10.1002/mus.20709 |s2cid=29048674 |type=Research Support, Non-U.S. Gov't}}</ref><ref name="nijeboer-etal-2013">{{cite journal |vauthors=Nijeboer P, Bontkes HJ, Mulder CJ, Bouma G |title=Non-celiac gluten sensitivity. Is it in the gluten or the grain? |journal=Journal of Gastrointestinal and Liver Diseases |volume=22 |issue=4 |pages=435–40 | date=December 2013 |pmid=24369326 |doi= |type=Review}}</ref> also neuropsychiatric manifestations ("[[gluten-sensitive idiopathic neuropathies]]") have been reported on.<ref name="GenuisLobo2014">{{cite journal|vauthors=Genuis S, Lobo RA |title=Gluten Sensitivity Presenting as a Neuropsychiatric Disorder|journal=Gastroenterology Research and Practice|volume=2014|year=2014|pages=1–6|issn=1687-6121|doi=10.1155/2014/293206|pmid=24693281|type=Review|pmc=3944951|doi-access=free}}</ref>

Studies using [[anti-gliadin antibodies]] (AGA) reveal that {{clarify|text=diagnosed or untreated|reason=Diagnosed/untreated for what?|date=December 2014}} individuals with AGA have an increasing risk for lymphoid cancers and decreased risk for other conditions associated with affluence.<ref name="pmid17206762">{{cite journal |vauthors=Anderson LA, McMillan SA, Watson RG, etal | title = Malignancy and mortality in a population-based cohort of patients with coeliac disease or "gluten sensitivity" | journal = World J. Gastroenterol. | volume = 13 | issue = 1 | pages = 146–51 | year = 2007 | pmid = 17206762 | pmc = 4065872 | doi = 10.3748/wjg.v13.i1.146 | type=Retrospective Studies | doi-access = free }}</ref>

The pathogenesis of NCGS is not yet well understood. There is evidence that not only [[gliadin]] (the main cytotoxic antigen of gluten), but also other proteins named ATIs which are present in gluten-containing cereals ([[wheat]], [[rye]], [[barley]], and their derivatives) may have a role in the development of symptoms. ATIs are potent activators of the [[innate immune system]].<ref name="FasanoSapone2015">{{cite journal |vauthors=Fasano A, Sapone A, Zevallos V, Schuppan D|title=Nonceliac gluten sensitivity |journal=Gastroenterology |volume=148|issue=6|pages=1195–204|date=May 2015|pmid=25583468 |doi=10.1053/j.gastro.2014.12.049|type=Review|doi-access=free}}</ref><ref name=Verbeke2018 /> [[FODMAP]]s, especially [[fructans]], are present in small amounts in gluten-containing grains and have been identified as a possible cause of some gastrointestinal symptoms in persons with NCGS.<ref name=FasanoSapone2015 /><ref name="VoltaCaioQuestions" /><ref name=Verbeke2018 /><ref name=OntiverosHardy>{{cite journal |vauthors=Ontiveros N, Hardy MY, Cabrera-Chavez F |title=Assessing of Celiac Disease and Nonceliac Gluten Sensitivity |journal=Gastroenterology Research and Practice |volume=2015 |issue= |pages=1–13 |year=2015 |pmid=26064097 |pmc=4429206 |doi=10.1155/2015/723954 |type=Review |doi-access=free }}</ref> As of 2019, reviews have concluded that although FODMAPs may play a role in NCGS, they only explain certain gastrointestinal symptoms, such as [[bloating]], but not the [[#Extraintestinal|extra-digestive symptoms]] that people with NCGS may develop, such as [[neurological disorder]]s, [[fibromyalgia]], psychological disturbances, and [[dermatitis]].<ref name=Verbeke2018 /><ref name=VoltaDeGiorgio2019 /><ref name="FasanoSapone2015" />

[[Triticeae glutens|''Triticeae'' glutens]] are important factors in several inflammatory diseases. The immunochemistry can be subdivided into innate responses (direct stimulation of immune system), [[MHC class II|class II]] mediated presentation ([[HLA-DQ]]), [[MHC class I|class I]] mediated stimulation of [[killer cells]], and [[antibody]] recognition. The responses to [[gluten]] proteins and [[polypeptide]] regions differs according to the type of gluten sensitivity. The response is also dependent on the genetic makeup of the [[human leukocyte antigen]] genes. In enteropathy, there are at least 3 types of recognition, [[innate immunity]] (a form of cellular immunity priming), HLA-DQ and antibody recognition of gliadin and transglutaminase.<ref name="pmid16766754">{{cite journal |vauthors=van Heel DA, West J |title=Recent advances in coeliac disease |journal=Gut |volume=55 |issue=7 |pages=1037–46 |date=July 2006 |pmid=16766754 |pmc=1856316 |doi=10.1136/gut.2005.075119 |type=Review}}</ref> In NCGS, there is high [[Anti-gliadin antibodies#Anti-gliadin IgG|AGA IgG]] in more than half of the cases.<ref>{{cite journal|author=Catassi C, Bai J, Bonaz B, Bouma G, Calabrò A, Carroccio A, Castillejo G, Ciacci C, Cristofori F, Dolinsek J, Francavilla R, Elli L, Green P, Holtmeier W, Koehler P, Koletzko S, Meinhold C, Sanders D, Schumann M, [[Detlef Schuppan|Schuppan D]], Ullrich R, Vécsei A, Volta U, Zevallos V, Sapone A, [[Alessio Fasano|Fasano A]]|title=Non-celiac gluten sensitivity: the new frontier of gluten related disorders|journal=Nutrients|volume=5|issue=10|year=2013|pages=3839–3853|issn=2072-6643|doi=10.3390/nu5103839|pmid=24077239|type=Review|pmc=3820047|doi-access=free}}</ref> In [[wheat allergy]], there appears to be an innate component and the response pathways are mediated through IgE against gliadin and other wheat proteins.<ref name="pmid18036646">{{cite journal |vauthors=Bittner C, Grassau B, Frenzel K, Baur X |title=Identification of wheat gliadins as an allergen family related to baker's asthma|issue=3 |pages=744–9 |date=March 2008 |pmid=18036646 |doi=10.1016/j.jaci.2007.09.051 |type=Research Support, Non-U.S. Gov't |volume=121 |journal=Journal of Allergy and Clinical Immunology}}</ref><ref name="pmid18186814">{{cite journal |vauthors=Matsuo H, Dahlström J, Tanaka A, etal |title=Sensitivity and specificity of recombinant omega-5 gliadin-specific IgE measurement for the diagnosis of wheat-dependent exercise-induced anaphylaxis |journal=Allergy |volume=63 |issue=2 |pages=233–6 |date=February 2008 |pmid=18186814 |doi=10.1111/j.1398-9995.2007.01504.x|s2cid=46107806 |type=Evaluation Studies}}</ref><ref name="pmid17655322">{{cite journal |vauthors=Akagawa M, Handoyo T, Ishii T, Kumazawa S, Morita N, Suyama K |title=Proteomic analysis of wheat flour allergens |journal=Journal of Agricultural and Food Chemistry |volume=55 |issue=17 |pages=6863–70 |date=August 2007 |pmid=17655322 |doi=10.1021/jf070843a |type=Research Support, Non-U.S. Gov't}}</ref>

A literature review of 2014 found that people suffering fromwith NCGS "are a heterogeneous group, composed of several subgroups, each characterized by different pathogenesis and clinical history, and, probably, clinical course".<ref name="mansueto-etal-2014">{{cite journal|author1=Mansueto P |author2=Seidita A |author3=D’Alcamo A |author4=Carroccio A |title=Non-Celiac Gluten Sensitivity: Literature Review|journal=Journal of the American College of Nutrition|volume=33|issue=1|year=2014|pages=39–54|issn=0731-5724|doi=10.1080/07315724.2014.869996|pmid=24533607|type=Review|hdl=10447/90208 |s2cid=22521576 |hdl-access=free}}</ref>

Celiac disease (CD) and NCGS are closely linked with [[human leukocyte antigen]] (HLA) class II genes, [[HLA-DQ2]] and [[HLA-DQ8]], located on [[Chromosome 6 (human)#p-arm|chromosome 6p21]].<ref name="sapone-etal-2010-b">{{cite journal |vauthors=Sapone A, Bai JC, Ciacci C, Dolinsek J, Green PH, Hadjivassiliou M, Kaukinen K, Rostami K, Sanders DS, Schumann M, Ullrich R, Villalta D, Volta U, Catassi C, Fasano A |title=Spectrum of gluten-related disorders: consensus on new nomenclature and classification |journal=BMC Medicine |volume=10 |issue= |pages=13 |year=2012 |pmid=22313950 |pmc=3292448 |doi=10.1186/1741-7015-10-13 |type=Review |doi-access=free }}</ref> Nearly all CD people are HLA-DQ2/HLA-DQ8 positive, with 95% HLA-DQ2 and the rest usually HLA-DQ8 (which is carried by 30% of Caucasians).<ref name="sapone-etal-2010-b"/> However, the [[Sensitivity and specificity|specificity]] of HLA-DQ2 and/or HLA-DQ8 for CD is low, with estimates ranging from 36% to 53%. In persons with NCGS, the HLA-DQ2 and/or HLA-DQ8 alleles are present in only about 50%, which is still a greater proportion than in the general population.<ref name="sapone-etal-2010-b"/>

Eliminating the possibility of CD can generally also be done by adding [[HLA-DQ]] typing. The absence of HLA-DQ2 and HLA-DQ8 has a very high negative predictive value for CD,<ref name="sapone-etal-2010-b"/><ref name="LebwohlGreen2012">Lundin KEA, Alaedini A, ''Non-celiac Gluten Sensitivity''. In: {{cite book|vauthors=Lebwohl B, Green PH |title=Celiac Disease, An Issue of Gastrointestinal Endoscopy Clinics|url=https://books.google.com/books?id=mWBFEpD2TrQC|date=1 November 2012|publisher=Elsevier Health Sciences|isbn=978-1-4557-4735-1|pages=}}</ref> and the predictive value can be further enhanced by including [[HLA-DQ7#DQ7.5|HLA-DQ7.5]] (HLA-DQ2 and HLA-DQ8 are found in coeliac disease 98% of the time in Caucasians, HLA-DQ7.5 present in the remaining 1.6% and only 0.4% of Caucasians are missed with the combination of these 3three).{{citation needed|date=January 2015}} Without serological or HLA-DQ2/8 positivity, celiac disease is likely not present. HLA-DQ typing has a practical advantage in that it is the only diagnostic test that allows to exclude CD when a person is already on a gluten-free diet; however, as not only celiacs are HLA-DQ2/HLA-DQ8 positive, this method has a higher false positive rate than anti-TG2 and EMA antibody testing.

A four-of-five rule was proposed 2010 for confirming celiac disease, with the disease confirmed if at least four of the following five criteria are satisfied:<ref name="sapone-etal-2010-b"/><ref name="pmid20670718">{{cite journal |vauthors=Catassi C, Fasano A |title=Celiac disease diagnosis: simple rules are better than complicated algorithms |journal=The American Journal of Medicine |volume=123 |issue=8 |pages=691–3 | date=August 2010 |pmid=20670718 |doi=10.1016/j.amjmed.2010.02.019 |hdl=11566/54123 |type=Research Support, Non-U.S. Gov't}}</ref>

For people with celiac disease, a lifelong strict gluten-free diet is the only effective treatment to date;<ref name="LamacchiaCamarca2014" /><ref name="Czaja-Bulsa-2014-table2">{{cite journal |author=Czaja-Bulsa G |title=Non coeliac gluten sensitivity -– A new disease with gluten intolerance |journal=Clinical Nutrition (Edinburgh, Scotland) |volume= 34|issue= 2|pages= 189–194| date=August 2014 |pmid=25245857 |doi=10.1016/j.clnu.2014.08.012 |type=Review|doi-access=free }} See [http://www.clinicalnutritionjournal.com/article/S0261-5614%2814%2900218-0/fulltext#tbl2 Table 2: Characteristics of gluten-dependent disorders].</ref>

For people diagnosed with non-celiac gluten sensitivity, there are still open questions concerning for example the duration of such a diet. The results of a 2017 study suggest that non-celicaceliac gluten sensitivity may be a chronic disorder, as is the case with celiac disease.<ref name=VoltaDeGiorgio2019 />

Preferably, newly diagnosed celiacs seek the help of a dietician to receive support for identifying hidden sources of gluten, planning balanced meals, reading labels, food shopping, dining out, and dining during travel.<ref name="pmid24444577">{{cite journal |vauthors=Pelkowski TD, Viera AJ |title=Celiac disease: diagnosis and management |journal=American Family Physician |volume=89 |issue=2 |pages=99–105 | date=January 2014 |pmid=24444577 |doi= |url=}}</ref> Knowledge of hidden sources of gluten is important for people with celiac disease as they need to be very strict regarding eating only gluten-free food.<ref>{{cite journal|vauthors=Cristofori F, Arezzo F, Gentile A, Francavilla R |s2cid=71854723|title=Gluten Sensitivity in Pediatrics: A Clinical Conundrum|journal=Current Pediatrics Reports|date=September 2014|volume=2|issue=3|pages=204–210|doi=10.1007/s40124-014-0053-9|doi-access=free}}</ref> The degree of gluten [[cross contamination]] tolerated by people with non-celicaceliac gluten sensitivity is not clear but there is some evidence that they can present with symptoms even after consumption of small amounts.<ref name=VoltaCaio2015 /> Sporadic accidental contaminations with gluten can reactivate [[movement disorder]]s associated with non-celicaceliac gluten sensitivity.<ref name=VinagreAragonZis>{{cite journal| vauthors=Vinagre-Aragón A, Zis P, Grunewald RA, Hadjivassiliou M| title=Movement Disorders Related to Gluten Sensitivity: A Systematic Review | journal=Nutrients | year= 2018 | volume= 10 | issue= 8 | page=1034 | pmid=30096784 | doi=10.3390/nu10081034 | pmc=6115931 | type=Systematic Review | doi-access=free }} </ref> A part of people with gluten-related neuropathy or [[ataxia#Gluten ataxia|gluten ataxia]] appears not to be able to tolerate even the traces of gluten allowed in most foods labeled as "gluten-free".<ref name=HadjivassiliouGrunewald2002>{{cite journal| vauthors=Hadjivassiliou M, Grünewald RA, Davies-Jones GA| title=Gluten sensitivity as a neurological illness. | journal=J Neurol Neurosurg Psychiatry | year= 2002 | volume= 72 | issue= 5 | pages= 560–3 | pmid=11971034 | doi= 10.1136/jnnp.72.5.560| pmc=1737870 | type=Review }} </ref>

The inclusion of [[oats]] in gluten-free diets remains controversial. [[Oat#Protein|Avenin]] present in oats may also be toxic for coeliacindividuals suffererswith celiacs.<ref name=PenaginiDilillo>{{cite journal | vauthors = Penagini F, Dilillo D, Meneghin F, Mameli C, Fabiano V, Zuccotti GV| title = Gluten-free diet in children: an approach to a nutritionally adequate and balanced diet | journal = Nutrients | volume = 5| issue = 11| pages = 4553–65| date = November 18, 2013| pmid = 24253052|pmc= 3847748| doi = 10.3390/nu5114553| doi-access = free }}</ref> Its toxicity depends on the [[cultivar]] consumed.<ref name=CominoMoreno>{{cite journal | vauthors = Comino I, Moreno Mde L, Sousa C | title = Role of oats in celiac disease | journal = World J Gastroenterol | volume = 21 | issue = 41 | pages = 11825–31 | date = November 7, 2015 | pmid = 26557006 |pmc= 4631980 | doi = 10.3748/wjg.v21.i41.11825 | doi-access = free }}</ref> Furthermore, oats are frequently cross-contaminated with gluten-containing cereals.<ref name=PenaginiDilillo />

Gluten proteins have low [[Nutrition|low nutritional and biological valuenutrition]]al value and replacing grains that contain gluten is easy from the nutritional point of view.<ref name=LamacchiaCamarca2014>{{cite journal |vauthors=Lamacchia C, Camarca A, Picascia S, Di Luccia A, Gianfrani C |title=Cereal-based gluten-free food: how to reconcile nutritional and technological properties of wheat proteins with safety for celiac disease patients |journal=Nutrients |volume=6 |issue=2 |pages=575–90 |year=2014 |pmid=24481131 |pmc=3942718 |doi=10.3390/nu6020575 |type=Review}}</ref> However, an unbalanced selection of food and an incorrect choice of gluten-free replacement products may lead to nutritional deficiencies. Replacing flour from wheat or other gluten-containing cereals with gluten-free flours in commercial products may lead to a lower intake of important nutrients, such as [[iron]] and [[B vitamins]]. Some gluten-free commercial replacement products are not enriched or fortified as their gluten-containing counterparts, and often have greater [[lipid]]/[[carbohydrate]] content. Children especially often over-consume these products, such as snacks and biscuits.<ref name=PenaginiDilillo />

[[Pseudocereal]]s ([[quinoa]], [[amaranth]], and [[buckwheat]]) and some minor cereals are healthyhealthier alternatives to these prepared products and have high biological andhigher nutritional value.<ref name=PenaginiDilillo /><ref name=LamacchiaCamarca2014 /> Furthermore, they contain protein of higher nutritional quality than those of wheat, and in greater quantities.<ref name=PenaginiDilillo />

In the United States, fewer cases of CD have been found compared to other countries.<ref>Boettcher,{{cite Ericajournal and|last1=Benson Ramesh|first1=Amanda K.|title=The Gandhi.Rise "Celiacand Disease."Fall ''Primaryof CareBread Reports'',in vol.America 18,|journal=Academic no.Symposium 12,of Dec.Undergraduate 2012,Scholarship pp.|date=1 153-167.April EBSCO''host'',2013 http|url=https://searchscholarsarchive.ebscohostjwu.comedu/login.aspx?directac_symposium/21/ |citeseerx=true&db=a9h&AN=83835158&site=ehost-live&scope=site10.1.1.675.2079 }}</ref> The incidence of celiac disease and of wheat allergy is estimated each to lie at around 1% of the population. There has been a 6.4 increase in the case reports of celiac disease between 1990 and 2009.<ref name="coeliac disease in children"/> The incidence of NCGS is unknown; some estimates range from 0.6% to 6%,<ref name="Czaja-Bulsa-2014-table2"/> and a systematic review of 2015 reported on studies with NCGS prevalence rates between 0.5% and 13%.<ref name="pmid25753138">{{cite journal |vauthors=Molina-Infante J, Santolaria S, Sanders DS, Fernández-Bañares F |title=Systematic review: noncoeliac gluten sensitivity |journal=Alimentary Pharmacology & Therapeutics |volume=41 |issue=9 |pages=807–20 |year=2015 |pmid=25753138 |doi=10.1111/apt.13155 |type=Review|doi-access=free }}</ref>

For Europe, the ''Commission Regulation (EC) No. 41/2009 of 20 January 2009 concerning the composition and labelling of foodstuffs suitable for people intolerant to gluten'' has laid down harmonised rules on the content and labelling of these foodstuffs, setting out the conditions under which foods may be labelled as "gluten-free" or "very low gluten".<ref>{{cite web|url=http://eur-lex.europa.eu/legal-content/EN/TXT/?qid=1420391798410&uri=URISERV:sa0024|title=Gluten-free foodstuffs|publisher=EUR-Lex|date=22 February 2011|accessdateaccess-date=4 January 2015}}</ref> Having entered into force on 10 February 2009 and taken effect on 1 January 2012, these rules have been repealed with effect as of 20 July 2016. The background is that, in line with the ''Regulation (EU) No 609/2013 on food for specific groups'', gluten-free foods shall, in future, be legislated for under the EU Food Information for Consumers Regulation ([[Regulation (EU) No. 1169/2011]]). Furthermore, the ''Commission Implementing Regulation (EU) No 828/2014 of 30 July 2014 on the requirements for the provision of information to consumers on the absence or reduced presence of gluten in food'' extends the rules of Regulation (EC) 41/2009 on "gluten-free" and "very low gluten" statements also to non pre-packed foods such as those served in restaurants. The implementing regulation also clarifies how consumers are to be informed of the difference between foods that are naturally free of gluten and products that are specially formulated for gluten-intolerant persons.<ref>{{cite web|url=http://ec.europa.eu/food/food/labellingnutrition/glutten-free-foods/index_en.htm|title=Foods for people intolerant to gluten (gluten-free foods)|publisher=European Commission|accessdateaccess-date=4 January 2015}}</ref>

Recognition of gluten-free packaged foods is facilitated by the crossed-grain symbol, representing a crossed [[Ear (botany)|ear]] of wheat. The symbol is used as a logo that facilitates food shopping for people with CD and other gluten-related disorders. The symbol, which is protected as a trademark in Europe and the United States and is covered by worldwide copyright, can be represented in any colour.<ref>{{cite web|url=http://www.coeliac.org.uk/food-industry-professionals/the-crossed-grain-symbol/|title=The Crossed Grain Symbol|publisher=Coeliac UK|accessdateaccess-date=12 January 2015}}</ref><ref>{{cite web|url=http://www.aoecs.org/?id=-31|title=Licensing the Crossed Grain symbol|publisher=Association of European Coeliac Societies (AOECS)|accessdateaccess-date=12 January 2015}}</ref>

Research has attempted to discern, by [[double-blind placebo-controlled trial]]s, between a "fad component" to the recent popularity of the [[gluten-free diet]] and an actual sensitivity to gluten or other components of wheat.<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref>{{cite journal |vauthors=Di Sabatino A, Volta U, Salvatore C, Biancheri P, Caio G, De Giorgio R, Di Stefano M, Corazza GR |title=Small Amounts of Gluten in Subjects with Suspected Nonceliac Gluten Sensitivity: A Randomized, Double-Blind, Placebo-Controlled, Cross-Over Trial |journal=Clinical Gastroenterology and Hepatology |volume=13 |issue=9 |pages=1604–12 |year=2015 |doi=10.1016/j.cgh.2015.01.029 |pmid=25701700|hdl=11392/2375087 |url=https://www.cghjournal.org/article/S1542-3565(15)00153-6/fulltext |doi-access=free |hdl-access=free }}</ref>