Celiac Disease Means Going Gluten Free

gluten-free

Could You Be Gluten Intolerant?

Celiac disease means going gluten free. But what does this mean for you? Let’s explore this topic a little in depth, and then look at some suggestions a little further on. Celiac disease (CD) was first described by a man called Samuel Gee in 1888, although a similar description of a chronic malabsorption disorder dates back as far as the second century. Gee described the classic features of celiac disease as diarrhoea, lassitude, and failure to thrive; he believed that the regulation of food was the main part of the treatment and noted that the disease was not age-specific.Since this time, a lot has been learned about the diagnosis and treatment of CD, particularly the past ten years.This comprehensive page examines how CD affects a person, how the disease develops, the typical signs and symptoms, the diagnosis, and the treatment.

Celiac disease is an auto-immune condition which results from the body having an allergic reaction towards gluten. The onset can be sudden and severe and it doesn’t take much gluten for a celiac to have a very strong reaction. celiac disease occurs when the proteins found in gluten (glutenin and gliadin) produce an immune system reaction, triggering antibody production. Over time, these antibodies can negatively affect the tiny little villi which line the walls of your small intestine in a process called villous atrophy. These microscopic finger-like tiny hairs are surrounded by nutrients as food passes through the stomach and into the small intestine. The small intestine is made up of three different sections – the duodenum, jejenum and the ileum. The duodenum contains the most amount of villi, and it is generally this part of the digestive system which is most affected by gluten. As celiac disease slowly destroy these tiny villi, you will become less and less able to break down and absorb the nutrients from the foods you consume. You can imagine what happens over time, you will eventually become increasingly deficient in many different nutrient resulting in many potential health problems. celiac disease is a mal-absorption health problem with a wide range of damaging health effects, particularly if it remains undiagnosed in a person. This damage can cause a wide variety of consequences, including maldigestion and malabsorption of nutrients, vitamins, and minerals in the digestive tract. Over time, numerous organ systems–including the skin, liver, nervous system, bones, reproductive system, and endocrine system–can be negatively affected by celiac disease.Treatment of celiac disease consists of the removal of gluten proteins from the diet, which improves and often eliminates the small-intestine pathology.

How does Celiac Disease Develop?

celiac-disease-villi-normalTwo primary factors are thought to contribute to the development of celiac disease are by way of consuming gluten proteins and genetic predisposition. It is not completely understood how gluten sensitivity begins or whether early exposure to gluten proteins increases the risk of sensitivity. Most experts agree that celiac disease results from an “unchecked” immune reaction to gluten and that this reaction results in inflammation of the proximal small intestine, where the partially digested gluten proteins make contact with the gut’s immune system.This immune response extends beyond just a direct reaction to the exogenous substance, also involving a potent, multifaceted immune response to the exogenous substance that results in substantial damage to the structure and function of the gut and other organs.

Genetics certainly have shown to play a role in the development of celiac disease, and environmental factors like a child’s diet early in life may also affect the risk of developing celiac disease. Just like an increased allergic response to dairy products such as cow’s milk, the risk of celiac disease appears to increase when large amounts of gluten are consumed in a person’s diet during their first year of life. Breast-feeding has shown to give a consistent protective effect; and the risk of dairy allergies as well as celiac disease decreases when a child is still being breast-fed at the time dietary dairy protein or gluten is introduced.Interestingly, a recent study found that, in children prone to developing celiac disease, an initial exposure to wheat, spelt, barley and rye in the first three months significantly increased the risk of developing celiac disease-associated auto-antibodies.

Articles on Gluten Intolerance and Celiac Disease

The Prevalence of Celiac Disease

Not all that long ago, celiac disease was thought to be extremely rare in countries like America, Australia and New Zealand. In America for example, studies published before the year 2000 estimated that between one in 4,800 and one in 10,000 people in the U.S. were affected by celiac disease. In recent years however, population studies suggest a much higher prevalence, particularly in people of European ancestry.One of the largest studies in America involved 13,145 participants who underwent screening for celiac disease. The prevalence of celiac disease was an amazing 1 in 22 in first-degree relatives, 1 in 39 in second-degree relatives, 1 in 56 in symptomatic patients, and an incredible 1 in 133 in those deemed “not at risk”. This is a far cry from the one in 4,800 people originally believed to have celiac disease prior to the year 2000.

The likelihood of having celiac disease increases to 10% to 20% in persons who have a first-degree relative with the disease. People who have type 1 diabetes mellitus, Down’s syndrome, or other disorders are at increased risk for developing celiac disease.

Celiac disease appears to be a disease predominantly of those of European descent. It is interesting to note that the people from the Punjab and Gujarat regions of India who have lived in England developed celiac disease almost 3 times as often as Europeans on a gluten-rich diet, probably because their diet early in life was not as gluten rich as those living in the UK. Some people who live in the tropical regions complain of a disease called “summer diarrhoea” which seems to be more prevalent during the summer months, this appears to be linked with an increase in consumption wheat which commonly replaces maize at this time of year.

Common Signs and Symptoms of Celiac Disease

celiac_iceberg_I have found that the clinical picture of celiac disease can vary markedly according to the age of the patient, the duration and extent of their celiac disease, and the presence of the destruction of the villi in the small intestine.

What I take into account are the symptoms they have when they come to see me as a naturopath, and what kind of immune system abnormalities they present with. The longer the patient has had celiacs disease, the more likelihood the will be malnourished, quite underweight and showing various signs and symptoms on vitamin and mineral deficiencies.

 

Celiac’s can be classified into 3 forms: classic (typical), atypical, and silent (no symptoms).

 

Classic Celiac Disease

baby_feedingThese are probably the easiest cases of CD to diagnose, the child’s developmental state typically is very compromised and the doctor or paediatrician will be quick to recommend a complete gluten avoidance and examination and testing.

Classic celiac disease typically presents in infancy from around age 6 up to 18 months, and will manifest itself as failure to thrive, diarrhoea, abdominal distention, muscle-wasting, developmental delay, and occasionally as quite severe malnutrition. Symptoms this condition can typically begin a mere weeks to months after the introduction of weaning foods containing and soon there is a decrease in weight gain with an obvious problem with the child’s percentile for weight and weight for height ratio. On some occasions, the child is rushed to the paediatric wing of the hospital and then diagnosed with the disorder which can potentially lead to a true medical emergency. Like many other conditions, celiac disease becomes much less of an emergency as the child grows older. Older children with celiac disease end up at the doctor’s surgery with obvious developmental delay such as short stature, bowel complaints or pain and some with dental enamel defects. I have seen several such children over the years, and when parasites, dysbiosis and candida yeast infections are ruled out I suspect celiac disease and encourage the parents to enforce a strict no-gluten diet. You would be surprised how quickly these children can improve, sometimes within 24 hours they notice a dramatic improvement in health.

Did you know that an amazing 75% of the newly diagnosed classic celiac disease cases are women? And these cases often are the ones which clearly stand out but are commonly missed, or passed off as “irritable bowel syndrome”. I have found it very difficult in many cases convincing a female patient to go gluten-free, especially if she has a family including one or several children. In both men and women, the typical digestive tract symptoms of celiac disease include diarrhoea, constipation, and other symptoms which can indicate malabsorption such as bloating, lots of flatus and burping. You will often find these digestive complaints to be accompanied with other complaints which occur as a consequence of the malabsorption such as weight-loss, failure to thrive (not enjoying life), anaemia (which may be severe), Vitamin B12 deficiency (have this checked if you are suspicious of CD), and many other potential signs and symptoms of B Vitamin deficiencies . I have found that some women presented as being underweight and having been on a vegan or a strict vegetarian diet for years, in the belief that they are allergic to many foods or have developed environmental toxicities from sprays, weedicides, pesticides, etc, when in that they have celiac disease which was never diagnosed.  These women need to be assessed for low bone mass (osteopaenia) and for Vitamin D and calcium deficiency.

A-typical Celiac Disease

These are the unusual cases and a-typical means not so commonly seen. You will find these people to have not so many gastrointestinal symptoms, and their complaints are of a more generalised nature and therefore often dismissed as being a hypochondriac, “it’s all in your head” syndrome or worse – a psychiatric patient with delusions. That is exactly what one lady told me her physician diagnosed her as, needing psychiatric help, when later it turned out she had celiac disease. Do you have complaints which are chronic but mild in nature, problems which have gone on for many years and no doctor or therapist has a clue? These problems can range from “vague” feelings of unwellness to iron deficiency, being of short stature (with health problems), failing to feel great, osteoporosis in spite of weight-bearing exercise & plenty of calcium intake, being infertile yet have exhausted all channels (and don’t want IVF) and more. The symptoms with a-typical CD are milder and not as strong or violent in nature as in the classic CD cases.

Silent Celiac Disease

These are the “too hard basket” cases and are rarely diagnosed. I have often had my suspicion with patients over the years that they may be a celiac patient, it’s a hunch you get from being in practice for many years and having seen thousands of people. Doctors need to diagnose before they treat, I don’t – I just treat, and when I use my sixth sense in many cases my suspicions were correct. Patients with silent CD are picked up by conventional medical practitioners because they may mention of a family history of celiac disease, or when the doctor looks for something else, after performing a procedure like an upper endoscopic procedure at which time a sample of the person’s small intestinal trace lining is taken. It is important to remember that silent celiac disease patients are still at risk for complications of celiac disease.

Diagnosing Celiac Disease

blood test for celiacYou will find that there is no one single test which is standard for celiac disease. Blood testing and a biopsy of the small intestine are universally accepted as being the best clinical markers and the most specific for making the diagnosis very accurate. If you have a family history of CD, or are at a higher risk (like have an auto-immune disease) then you are best to get checked out for CD if you can relate to the signs and symptoms and are not satisfied with your current diagnosis or treatment. It is important to remember that diagnostic testing must be performed while you are on a diet that includes gluten-containing foods. What it the point otherwise? Your immune system won’t be challenged and the results may well be inconclusive, so, as uncomfortable as it is, it is best that you consume gluten containing foods before testing. What you may not be aware of is that blood testing may not be as accurate in children under 5 years of age, and in these cases I’d just recommend you do the strict gluten-free diet.

As a general rule, testing for CD should begin with the blood test.Forget the antigliadin antibody test if you want accuracy, this test has a lower sensitivity and specificity than the following tests I am going to recommend. Here are the two best blood tests to have performed if you want to know if you have CD, these tests are equally as accurate and are considered to be up to 85% to 100% sensitive and 96% to 100% specific for celiac disease.

  • Immunoglobulin A (IgA) antitissue transglutaminase
  • IgA endomysial antibody

If you are found to be positive for one of these blood tests, you should then undergo a small bowel biopsy, which is not as uncomfortable as it sounds. If you are at a high risk, in spite of your blood tests, I still think you should undergo this procedure, especially if there are strong reasons to suspect CD.

If you have tested positive as far as the blood test is concerned, and have a positive test result in terms of the biopsy, you can pretty much guarantee that you have CD and the test results are certainly conclusive. I have seen many patients however who were positive on a blood test you the biopsy was “inconclusive” yet their health improved dramatically once all sources of gluten were removed from their diet. The biopsy appears to be the more accurate, especially if you have classic CD. But always remember this – a negative test result does not mean you do not have the disease, it just means they couldn’t find it with their test. You will find the whether there is a diagnosis or not, once gluten is gone and the person improves that’s all he proof you want.

It is especially important to diagnose CD early in a child’s life, because it can help prevent many health problems down the track. As the tree is bent, so shall it grow. That child’s risk of developing other autoimmune diseases and serious intestinal disease is in direct proportional to the time of exposure to gluten.

For this reason in America, the National Institutes of Health consensus statement on celiac disease (2004) recommends testing for CD in any patient at high risk for developing CD; such as those experiencing digestive problems (if not otherwise explained) such as chronic diarrhoea, malabsorption, weight loss, and abdominal pain and/or distention. Patients who should also be tested are those lacking another explanation for signs and symptoms (e.g., short stature, delayed development, iron-deficiency anaemia, and infertility).

Treating Celiac Disease

Treating CD pretty straightforward, the most effective treatment for celiac disease is a strict lifelong adherence to a gluten-free diet.All food, drinks containing gluten (found in wheat, barley, oats, rye, and their derivatives) should be completely eliminated from the diet. But it is not that easy! Just about everything you touch in a supermarket contains gluten in one form or another.
One of the biggest controversies in the treatment of celiac disease relates to the amount of gluten allowed. The American NFA (National Food Authority) has redefined the term “gluten-free”; previously, less than 0.02% gluten in a product was considered gluten-free. This has changed however, and gluten-free now means that the food must contain no gluten at all, and less than 0.02% gluten is labelled a “low-gluten” product.

Once CD has been identified and all foods & drinks containing gluten are stopped, the vast majority of CD patients will find a positive change with their symptoms in time, as well as a normalising of their blood test results. Growth and development in children will typically return to normal with adherence to the gluten-free diet, but this will occur over time ranging from weeks to months. In my experience, some symptoms (such as abdominal pain) often disappear in as little as 24 hours, whereas other symptoms such as being very malnourished and low body weight  can take a few months. Most of the long-term health complications of CD can be avoided if the condition is identified sooner rather than later. What is important is that the patient’s nutritional status is assessed, and that supplementation is generally advised in terms of vitamins, minerals and calories. CD is a condition that primarily affects the digestive system, and it stands to reason that any chronic health condition which adversely affects the functioning of the digestive system necessitates nutritional supplementation.

gluten free breadAdopting a Gluten-free Diet

Gluten is the main protein found in wheat, and it is therefore very important to avoid all forms of wheat and foods or products containing wheat. Barley, rye and spelt must also be avoided, as they contain proteins which are very similar to the gluten protein found in wheat. I am often asked by patients who want to avoid gluten if oats a problem. Although oats are not usually a problem in those who have CD, what you will find is the commercial oats is almost always contaminated with wheat or traces of wheat.

Good gluten-free flour choices are soybean (get the non-GMO) and tapioca flours, rice, corn, maize, buckwheat, potato flour, and other grain substitutes such as nut flours and bean flours.
Today, most supermarkets and all health-food shops will stock a good range of gluten free products. Products will include different flours, biscuits, breads, crackers and many different cereals. You will also found the more unusual items (particularly at health food shops) such as gluten-free soy sauce. In addition, meats, vegetables, fruits, and most dairy products are free of gluten as long as they were not contaminated during their production.

Going gluten free used to be a nightmare ten or twenty years ago, but today there are many different resources available for those today with CD, including cookbooks, gluten-free prepared foods, many Internet sites, and various gluten-free organisations.

Correcting Nutritional Deficiencies

A common deficiency encountered by those who have CD is the deficiency of the fat-soluble vitamins A, D, E, and K, and I always recommend supplementation. Another major deficiency you will encounter is an iron-deficiency anaemia, which is a very common of celiac disease, and anybody with CD should have a regular iron test to ascertain their levels. Be sure to test the ferritin (iron storage) as well as the serum iron levels. If there is evidence of any osteoporosis then I recommend a good calcium/magnesium supplement and vitamin D replacement. There are several other nutritional deficiencies which are common in CD that frequently require supplementation and these involve the minerals magnesium, zinc, selenium, copper, and folate. A good supplement to take in this regard is Ultra Preventive X which contains a superb range of all the vitamins and minerals required for optimal health.

One area often overlooked by those with CD, is the addition of plenty of fibre to the diet, because a gluten-free diet can often be constipating for many. Constipation usually responds to the addition of dietary rice bran or psyllium fibre and many digestive supplements today also are generally 100% gluten-free, just be sure to read the label carefully.

To Conclude

Being a celiac does not necessarily mean less enjoyment with life.
Sticking with a gluten-free diet remains the mainstay of therapy for celiac disease, and although a gluten-free diet seems simple to follow in theory, the CD diet can be very difficult for some patients to firmly adhere to.The most common reasons for lack of response are poor compliance to the strict dietary regime and inadvertent times when gluten will be accidentally ingested. I firmly believe that all patients with celiac disease should be reevaluated periodically, and this evaluation should include assessment of growth, assessment of the digestive system and any other symptoms commonly associated with celiac disease, as well as the individual patient’s understanding of and compliance with their gluten free-diet.

References

  • Fasano A, Catassi C. Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum. Gastroenterology. 2001;120:636-651.
  • Nelsen DA. Gluten-sensitive enteropathy (celiac disease): more common than you think. Am Fam Physician. 2002;66:2259-2266.
  • Presutti RJ, Cangemi JR, Cassidy HD, Hill DA. Celiac disease. Am Fam Physician. 2007;76:1795-1802.
  • Hill ID. Clinical Manifestations and Diagnosis of Celiac Disease in Children. Waltham, MA: UpToDate; 2008.
  • US Department of Health and Human Services. NIH Consensus Statement on Celiac Disease. NIH Consensus and State-of-the-Science Statements. June 28-30, 2004. http://consensus.nih.gov/2004/2004CeliacDisease118PDF.pdf. Accessed October 31, 2008.
  • Barton SH, Kelly DG, Murray JA. Nutritional deficiencies in celiac disease. Gastroenterol Clin North Am. 2007;36:93-108.
  • Barton SH, Murray JA. Celiac disease and autoimmunity in the gut and elsewhere. Gastroenterol Clin North Am. 2008;37:411-428.
  • Hill ID. Management of Celiac Disease in Children. Waltham, MA: UpToDate; 2007.
  • Niewinski MM. Advances in celiac disease and gluten-free diet. J Am Diet Assoc. 2008;108:661-672.
  • Branski D, Fasano A, Troncone R. Latest developments in the pathogenesis and treatment of celiac disease. J Pediatr. 2006;149:295-300.
  • National Digestive Diseases Information Clearinghouse. Celiac disease. NIH Publication No. 08-4269. http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/. Accessed October 31, 2008.
  • Schuppan D, Dieterich W. Pathogenesis, Epidemiology, and Clinical Manisfestations of Celiac Disease in Adults. Waltham, MA: UpToDate; 2008.
  • Ciclitira PJ. Management of Celiac Disease in Adults. Waltham, MA: UpToDate; 2008.
  • Norris J, Barriga K, Hoffenberg E, et al. Risk of celiac disease autoimmunity and timing of gluten introduction in the diet of infants at increased risk of disease. JAMA. 2005;293:2343-2351.
  • Rossi T, Albini C, Kumar V. Incidence of celiac disease identified by the presence of serum endomysial antibodies in children with chronic diarrhea, short stature, or insulin-dependent diabetes mellitus. J Pediatr. 1993;123:262-264.
  • Talley NJ, Valdovinos M, Petterson TM, et al. Epidemiology of celiac sprue: a community-based study. Am J Gastroenterol. 1994;89:843-846.
  • Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003;163:286-292.
  • Kelly CP. Diagnosis of Celiac Disease. Waltham, MA: UpToDate; 2008.
  • Plogsted S. Medications and celiac disease–tips from a pharmacist. Pract Gastroenterol. 2007;31:58-64.
  • Grabenstein JD. Pharmacy-Based Immunization Delivery: A National Certificate Program for Pharmacists. Washington, DC: American Pharmacists Association; 2008.

Last Page Update 14 July 2011

Comments on this entry are closed.