1. Morin, Karen H. PhD, RN, ANEF, FAAN

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Healthcare professionals are familiar with gluten-free diets for celiac disease. Recently gluten-free diets have increased in popularity, such that they are now the most trendy diet practice in the United States and other countries (Fasano, Sapone, Zevallos, & Schupper, 2015). Reasons for this increased popularity vary. Although a gluten-free diet may be used in an attempt to lose weight (Fasano et al.), there is increasing evidence that some individuals suffer from nonceliac gluten sensitivity (NCGS). Understanding differences between celiac disease, wheat allergy, and NCGS is important when assessing and discussing dietary habits.


How do celiac disease, wheat allergy, and NCGS differ? Wheat allergy and celiac disease are associated with an adaptive immune system, demonstrated by activation of T cells in the intestinal mucosa against gluten (Fasano et al., 2015). In wheat allergy, the response is demonstrated by the release of histamine. Conversely, celiac disease is an autoimmune disorder. Those with NCGS, however, do not have the same reaction to gluten; that is, their reaction does not lead to overt autoimmune enteropathy (Fasano et al.). They do, however, experience some of the symptoms when ingesting gluten products. The diagnosis of NCGS is made based on resolution of symptoms once gluten is removed from the diet and wheat allergy and celiac disease have been ruled out. The diagnosis of NCGS is controversial, however, as there is some evidence that gluten may not be the underlying cause of NCGS and the diagnosis itself is questioned by some investigators. Symptoms associated with NCGS include but are not limited to bloating, diarrhea, abdominal discomfort or pain, fatigue, headaches, and depression (Kovacs & Shiel, 2015).


What are the challenges associated with a gluten-free diet? One of the most common challenges is the ubiquitous nature of gluten. Gluten, a protein, is found in wheat, rice, and maize (Sapone et al., 2012). Of these, wheat is the most diverse and the most widely cultivated. Gluten is found in foods such as barley, flour, couscous, tabouli, and malt vinegar (Kovacs & Shiel, 2015). Pharmaceuticals and meat products frequently contain gluten. Not only should these foods be avoided, but, because cross-contamination is of concern (Kulai & Rashid, 2014), separate equipment (for example, a toaster or utensils) and separate storage containers are needed.


Although more gluten-free products are available, their nutritional content has been questioned. Kulai and Rashid (2014) found that gluten-free (GF) breads are higher in fat and lower in protein and iron content when compared to similar regular, gluten-containing products. Gluten-free pasta was noted to be lower in protein, iron, folate, and fiber and higher in carbohydrates than the similar gluten-containing product. Equally important was the finding that GF food products were over 11/2 times more expensive than their regular gluten-containing counterparts (Kulai & Rashid). Those adhering to a gluten-free diet may consume products higher in carbohydrate and fat content and lower in fiber, folate, iron, and protein than gluten products, raising concerns that GF products may contribute to overweight and obesity (Kulai & Rashid).


What does this mean for nurses? Assessing the nutritional patterns of families includes determining whether family members experience untoward symptoms when eating certain foods. Being knowledgeable about NCGS can provide direction for answering questions from patients who have celiac disease or diagnosed wheat allergy when they describe some of the nonspecific symptoms mentioned here. Helping identify gluten-free foods, such as buckwheat, lentils, garbanzo beans, and tapioca, can enhance an individual's willingness to try a GF diet while providing needed support. The National Foundation for Celiac Awareness offers further information at




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Kovacs B., Shiel W. C. (2015). Gluten-free diet. Retrieved from


Kulai T., Rashid M. (2014). Assessment of nutritional adequacy of packaged gluten-free food products. Canadian Journal of Dietetic Practice and Research, 75(4), 186-190. [Context Link]


Sapone A., Bai J. C., Ciacci C., Dolinsek J., Green P. H., Hadjivassiliou M., ..., Fasano A. (2012). Spectrum of gluten-related disorders: Consensus on new nomenclature and classification. BMC Medicine, 10, 13. doi:10.1186/1741-7015-10-13 [Context Link]