Neurocognitive symptoms in patients with celiac disease and non-celiac gluten sensitivity

Celiac disease is an autoimmune disorder that results from antibodies to components of gluten. Globally, about 0.7-1.4% of the population has celiac disease. When people with celiac disease eat gluten, their bodies respond by forming antibodies to components of the gluten protein. These antibodies also bind to the villi of intestinal cells, resulting in a variety of signs and symptoms. Classic celiac disease typically presents with localized gastrointestinal (GI) symptoms, including diarrhea, constipation, malabsorption, abdominal pain, bloating, and weight loss. Patients with non-classic celiac disease (which, interestingly, is more common than classic celiac disease) develop symptoms that do not significantly involve the GI tract. These signs and symptoms can include fatigue, joint pain, dermatitis herpetiformis, iron deficiency anemia, migraines, depression, attention deficit disorder, epilepsy, infertility, and low bone density. Some experts prefer to use the terms “intestinal” and “extraintestinal” in place of classic and non-classic celiac disease.

Non-celiac gluten sensitivity is characterized by signs or symptoms associated with gluten ingestion without laboratory findings associated with celiac disease or wheat allergy. Estimates of its prevalence range widely from 0.49% to 14.9%. Symptoms vary and may present in a wide variety of ways, like the intestinal and extraintestinal manifestations of celiac disease.

Neurocognitive symptoms are commonly described by patients with celiac disease; however, there has been little formal study of these symptoms. Neurologic effects of celiac disease have generally been limited to descriptions of neuropathy, epilepsy, and ataxia. A recent survey study of 1396 patients with celiac disease and non-celiac gluten sensitivity was conducted to better understand neurocognitive effects (referred to more informally as “brain fog”) in patients following gluten ingestion. Participants were recruited from the e-mail contact database and social media platforms of the patient advocacy organization Beyond Celiac. 9 in 10 participants reported acute neurocognitive symptoms after gluten ingestion, including forgetfulness, difficulty concentrating, and grogginess. Both groups also noted similar onset and peak of symptoms at 1-2 days, with many continuing to have symptoms 3-5 days later.

While limited by the self-selected population, this study suggests that both patients with celiac disease and non-celiac gluten sensitivity have neurocognitive symptoms following gluten ingestion. The duration of symptoms observed demonstrates the potential to significantly affect patients’ work and/or school performance. It may be helpful for family physicians to ask patients with celiac disease and non-celiac gluten sensitivity if they experience neurocognitive symptoms to better understand how these may be affecting their cognitive functioning and performance.

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Dr. White, a second-year resident at the Cleveland Clinic Family Medicine Residency Program, is a 2022 AFP Resident Representative.