Digestive Diseases and Sciences

, Volume 59, Issue 6, pp 1255–1261 | Cite as

Characteristics of Patients Who Avoid Wheat and/or Gluten in the Absence of Celiac Disease

  • Anna Tavakkoli
  • Suzanne K. Lewis
  • Christina A. Tennyson
  • Benjamin Lebwohl
  • Peter H. R. GreenEmail author
Original Article



Gastrointestinal symptoms that respond to the removal of wheat and/or gluten are becoming more common. Patients who avoid wheat and/or gluten (PWAWG) are a heterogeneous group and predominantly self-diagnosed prior to presenting for clinical evaluation.

Specific aim

We characterized PWAWGs seen at a tertiary care referral center and compared them to patients with celiac disease (CD) and subjects in the National Health and Nutrition examination survey (NHANES).


This was a cross-sectional study evaluating patients seen by four gastroenterologists at a CD referral center. Baseline characteristics, laboratory values, and medical comorbidities were compared to CD patients who presented at the same center and subjects enrolled in NHANES.


Eighty-four PWAWGs were identified and compared to 585 CD patients and 2,686 NHANES patients. Thirty-two alternative diagnoses were made in 25 (30 %) PWAWGs, including small intestinal bacterial overgrowth and fructose/lactose intolerance. When compared to patients with CD, PWAWGs had similar body mass index (BMI, 23.1 vs. 23.5, p = 0.54) and mean hemoglobin value (13.4 vs. 13.3, p = 0.6). When compared to male and female patients in NHANES, BMI, folate, and mean hemoglobin values were lower in PWAWGs. Both male and female PWAWGs had a lower prevalence of hypertension.


While there are similarities between CD and PWAWGs that could possibly be due to shared HLA haplotypes or an effect of the gluten-free diet, alternative diagnoses are common in these patients. PWAWGs have a similar cardiovascular profile as CD patients in terms of lower BMI and lower prevalence of hypertension.


Patients who avoid wheat and/or gluten Celiac disease Gluten-free diet Alternative diagnoses 


Conflict of interest



  1. 1.
    Rubio-Tapia A, Ludvigsson JF, Brantner TL, et al. The prevalence of celiac disease in the United States. Am J Gastroenterol. 2012;107:1538–1544.PubMedCrossRefGoogle Scholar
  2. 2.
    Ferch CC, Chey WD. Irritable bowel syndrome and gluten sensitivity without celiac disease: separating the wheat from the chaff. Gastroenterology. 2012;142:664–673.PubMedCrossRefGoogle Scholar
  3. 3.
    Ludvigsson JF, Leffler DA, et al. The Oslo definitions for coeliac disease and related terms. Gut. 2013;62:43–52.PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Di Sabatino A, Corazza GR. Nonceliac gluten sensitivity: sense or sensibility? Ann Intern Med. 2012;156:309–311.PubMedCrossRefGoogle Scholar
  5. 5.
    Troncone R, Jabri B. Coeliac disease and gluten sensitivity. J Intern Med. 2011;269:582–590.PubMedCrossRefGoogle Scholar
  6. 6.
    Sapone A, Bai JC, Ciacci C, et al. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Med. 2012;10:13.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Lundin KE, Alaedini A. Non-celiac gluten sensitivity. Gastrointest Endosc Clin N Am. 2012;22:723–734.PubMedCrossRefGoogle Scholar
  8. 8.
    Wahnschaffe U, Schulzke JD, Zeitz M, Ullrich R. Predictors of clinical response to gluten-free diet in patients diagnosed with diarrhea-predominant irritable bowel syndrome. Clin Gastroenterol Hepatol. 2007;5:844–850.PubMedCrossRefGoogle Scholar
  9. 9.
    Biesiekierski JR, Newnham ED, Irving PM, et al. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011;106:508–514.PubMedCrossRefGoogle Scholar
  10. 10.
    Brottveit M, Vandvik PO, Wojniusz S, et al. Absence of somatization in non-coeliac gluten sensitivity. Scand J Gastroenterol. 2012;47:770–777.PubMedCrossRefGoogle Scholar
  11. 11.
    Carroccio A, Mansueto P, Iacono G, et al. Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. Am J Gastroenterol. 2012;107:1898–1906.PubMedCrossRefGoogle Scholar
  12. 12.
    Biesiekierski JR, Peters SL, Newnham ED, et al. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterology. 2013;145:320.e3–328.e3. doi: 10.1053/j.gastro.2013.04.051.
  13. 13.
    Vazquez-Roque MI, Camilleri M, Smyrk T, et al. A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: effects on bowel frequency and intestinal function. Gastroeneterology. 2013;144:903–911.CrossRefGoogle Scholar
  14. 14.
    Cooper BT, Holmes GK, Ferguson R, et al. Gluten-sensitive diarrhea without evidence of celiac disease. Gastroenterology. 1981;81:192–194.PubMedGoogle Scholar
  15. 15.
    Brar P, Kwon GY, Holleran S, et al. Change in lipid profile in celiac disease: beneficial effect of gluten-free diet. Am J Med. 2006;119:786–790.PubMedCrossRefGoogle Scholar
  16. 16.
    Kabbani TA, Kelly CP, Betensky RA, et al. Patients with celiac disease have a lower prevalence of non-insulin-dependent diabetes mellitus and metabolic syndrome. Gastroenterology. 2013;144:912.e1–917.e1. doi: 10.1053/j.gastro.2013.01.033.
  17. 17.
    Cheng J, Brar PS, Lee AR, Green PH. Body mass index in celiac disease: beneficial effect of a gluten-free diet. J Clin Gastroenterol. 2010;44:267–271.PubMedCrossRefGoogle Scholar
  18. 18.
    Mubarak A, Wolters VM, Gerritsen SA, Gmelig-Meyling FH, Ten Kate FJ, Houwen RH. A biopsy is not always necessary to diagnose celiac disease. J Pediatr Gastroenterol Nutr. 2011;52:554.PubMedCrossRefGoogle Scholar
  19. 19.
    Thompson T, Dennis M, Higgins LA, Lee AR, Sharrett MK. Gluten-free diet survey: are Americans with coeliac disease consuming recommended amounts of fibre, iron, calcium and grain foods? J Hum Nutr Diet. 2005;18:163–169.PubMedCrossRefGoogle Scholar
  20. 20.
    Hallert C, Grant C, Grehn S, et al. Evidence of poor vitamin status in coeliac patients on a gluten-free diet for 10 years. Aliment Pharmacol Ther. 2002;16:1333–1339.PubMedCrossRefGoogle Scholar
  21. 21.
    Hallert C, Svensson M, Tholstrup J, Hultberg B. Clinical trial: B vitamins improve health in patients with coeliac disease living on a gluten-free diet. Aliment Pharmacol Ther. 2009;29:811–816.PubMedCrossRefGoogle Scholar
  22. 22.
    Howard MR, Turnbull AJ, Morley P, Hollier P, Webb R, Clarke A. A prospective study of the prevalence of undiagnosed coeliac disease in laboratory defined iron and folate deficiency. J Clin Pathol. 2002;55:754–757.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Ohlund K, Olsson C, Hernell O, Ohlund I. Dietary shortcomings in children on a gluten-free diet. J Hum Nutr Diet. 2010;23:294–300.PubMedCrossRefGoogle Scholar
  24. 24.
    Wild D, Robins GG, Burley VJ, Howdle PD. Evidence of high sugar intake, and low fibre and mineral intake, in the gluten-free diet. Aliment Pharmacol Ther. 2010;32:573–581.PubMedCrossRefGoogle Scholar
  25. 25.
    Rampertab SD, Pooran N, Brar P, Singh P, Green PH. Trends in the presentation of celiac disease. Am J Med. 2006;119:355e9–355e14.CrossRefGoogle Scholar
  26. 26.
    Hernandez L, Green PH. Extraintestinal manifestations of celiac disease. Curr Gastroenterol Rep. 2006;8:383–389.PubMedCrossRefGoogle Scholar
  27. 27.
    DiGiacomo DV, Tennyson CA, Green PH, Demmer RT. Prevalence of gluten-free diet adherence among individuals without celiac disease in the USA: results from the Continuous National Health and Nutrition Examination Survey 2009–2010. Scand J Gastro. 2013;48:921–925. doi: 10.3109/00365521.2013.809598.
  28. 28.
    Coburn JA, Vande Voort JL, Lahr BD, et al. Human leukocyte antigen genetics and clinical features of self-treated patients on a gluten-free diet. J Clin Gastroenterol. 2013;47:828–833. doi: 10.1097/MCG.0b013e31828f531c.Google Scholar
  29. 29.
    Green PH, Jabri B. Coeliac disease. Lancet. 2003;362:383–391.PubMedCrossRefGoogle Scholar
  30. 30.
    Brottveit M, Raki M, Bergseng E, et al. Assessing possible celiac disease by an HLA-DQ2-gliadin tetramer test. Am J Gastroenterol. 2011;106:1318–1324.PubMedCrossRefGoogle Scholar
  31. 31.
    Thewissen BG, Pauly A, Calus I, et al. Inhibition of angiotensin I-converting enzyme by wheat gliadin hydrolysates. Food Chem. 2011;127:1653–1658.CrossRefGoogle Scholar
  32. 32.
    Behall KM, Scholfield DJ, Hallfrisch J. Whole-grain diets reduce blood pressure in mildly hypercholesterolemic men and women. J Am Diet Assoc. 2006;106:1445–1449.PubMedCrossRefGoogle Scholar
  33. 33.
    Tighe P, Duthie G, Vaughan N, et al. Effect of increased consumption of whole-grain foods on blood pressure and other cardiovascular risk markers in healthy middle-aged persons: a randomized controlled trial. Am J Clin Nutr. 2010;92:733–740.PubMedCrossRefGoogle Scholar
  34. 34.
    Gaesser GA, Siddhartha AS. Gluten-free diet: imprudent dietary advice for the general population? J Acad Nutr Diet. 2012;112:1330–1333.PubMedCrossRefGoogle Scholar
  35. 35.
    Perrier C, Corthesy B. Gut permeability and food allergies. Clin Exp Allergy. 2011;41:20–28.PubMedCrossRefGoogle Scholar
  36. 36.
    Vanga R, Leffler D. Gluten sensitivity: not celiac and not certain. Gastroenterology. 2013;145(2):276–279. doi: 10.1053/j.gastro.2013.06.027.

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Anna Tavakkoli
    • 1
  • Suzanne K. Lewis
    • 1
  • Christina A. Tennyson
    • 1
  • Benjamin Lebwohl
    • 1
    • 2
  • Peter H. R. Green
    • 1
    Email author
  1. 1.Department of Medicine, Celiac Disease CenterColumbia UniversityNew YorkUSA
  2. 2.Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkUSA

Personalised recommendations