Celiac Disease and Gluten Sensitivity

Celiac disease (CD) is a hereditary autoimmune response to the gluten proteins found in wheat, spelt, kamut, rye, triticale, barley, and perhaps oats. This means that when a person with celiac disease eats a gluten-containing food, the person’s immune system mistakes the gluten proteins as foreign invaders and produces an inflammatory response in the small intestine. The inflammation causes the intestinal villi (the finger-like projections responsible for nutrient absorption) to become flattened, greatly reducing absorption of nutrients from foods. A multitude of health problems can result. Celiac disease is also called sprue, non-tropical sprue, and gluten sensitive enteropathy. Individuals with CD must eat a gluten-free diet to recover. There is also non-celiac gluten sensitivity, which differs from CD in that flattening of the intestinal villi does not occur.  However, non-celiac gluten sensitivity can also have many manifestations of unwellness.

Celiac disease is thought to affect less than 1% of the American population, whereas gluten sensitivity has been estimated to affect as much as 35%[1]. As do people with CD, individuals with gluten sensitivity need to adhere to a gluten-free diet. And while there is the possibility of overcoming non-celiac gluten sensitivity, CD is considered a permanent condition, requiring maintenance of a gluten-free diet for life.

The treatment of CD and gluten sensitivity is the same. In this article, “gluten intolerance” will refer to both CD and non-celiac gluten sensitivity.

Symptoms of Gluten Intolerance

Many symptoms of gluten intolerance are related to malabsorption. Diarrhea or constipation, abdominal pain, flatulence, distended abdomen, and greasy foul-smelling stools can result from food not being absorbed in the small intestine and instead being fermented by colonic bacteria. However, not everyone with gluten intolerance suffers these intestinal symptoms. Other manifestations of malabsorption can be anemia (poor absorption of iron), osteoporosis (poor mineral and vitamin absorption), weight loss or weight gain, fatigue, depression, and infertility. An itchy skin rash, called dermatitis herpetiformis, is frequently associated with CD. One type of epilepsy is also linked to CD.

In addition to poor absorption, persons reactive to gluten may also have gut hyperpermeability, also known as “leaky gut.” It is unclear whether gluten is the cause of the hyperpermeability or whether hyperpermeability is what causes the gluten intolerance. In gut hyperpermeability, large molecules—molecules that would normally be excluded from the blood by the intestinal mucosa—enter the bloodstream. These can create an overwhelming load on the liver’s detoxification capability and can result in many forms of illness, such as headaches, joint pain, muscle pain, skin problems, mental illness, cognitive issues, and autoimmune diseases (e.g., type 1 diabetes, rheumatoid arthritis, Hashimoto’s thyroiditis, lupus).

New research is also finding that issues relating to digestion and absorption are only the tip of the gluten-sensitivity iceburg. In fact, it is estimated that for every person diagnosed with celiac disease, there are eight undiagnosed celiacs that show no signs of digestive issues.[2] So far gluten has been linked to 55 different diseases and for the majority of those with Celiac disease or gluten sensitivity, damage to the brain, heart, skin, respiratory tract or the joints is more likely than outright digestive issues.[3] Completely eliminating gluten from the diet is a great step for those suffering from symptoms with unknown causes.

Testing for Celiac Disease and Gluten Sensitivity

Blood tests are often used as first-stage testing in doctors’ offices. The common ones test for the presence of IgG and IgA antibodies produced by the body in response to the following:

  • gliadin (a gluten protein)
  • tissue transglutaminase (tTG; an enzyme produced in the body)
  • endomysium (connective tissue surrounding muscle)

Presence of these antibodies in the blood suggests the possibility of CD or gluten sensitivity; absence of these antibodies suggests the symptoms are not likely due to CD. However, if the subject has been eating a gluten-free diet, there may be no antibodies even if he or she has CD. Also, absence of antibodies does not rule out gluten sensitivity. A new, improved, more accurate blood test is available with a doctor’s prescription through Genova Diagnostics. For a physician referral list go to http://www.gdx.net  (1-800-522-4762). The test rules out the 10% to 15% of false negatives of the older test.

Cyrex Laboratories is a new lab offering four highly sensitive tests to identify Gluten Sensitivity and its complications. Their Wheat/Gluten Proteome Reactivity and Autoimmunity (Array 3 Test) is able to test for a broader range of the components that make up gluten rather than the standard single component used in other testing. This test is able to more accurately assess gluten tolerance/intolerance in a broader range of individuals. Their Gluten-Associated Sensitivity and Cross-Reactive Foods (Array 4 Test) is able to test for sensitivities to other foods that the body may be mistaking for gluten. This test can be helpful for the person who knows or suspects gluten is problematic for them, but has not seen improvements with a gluten-free diet. http://www.cyrexlabs.com (1-602-759-1245)

There are also genetic tests that assess the probability of gluten intolerance. A positive result confirms gluten intolerance but cannot distinguish CD and gluten sensitivity.  A negative result rules out CD but not gluten sensitivity. This test can be ordered without a doctor’s prescription through http://www.enterolab.com,  the website of a government-registered, accredited laboratory (1-972-686-6869).

A more reliable test for gluten sensitivity is a stool analysis that looks for the same antibodies measured in the blood testing. (Since the antibodies are formed in the intestine, they may not enter the blood if there has not been significant damage to the intestine.) Stool analysis can recognize gluten sensitivity before major intestinal damage occurs. This test can be ordered without a doctor’s prescription through Entero Lab (see above).

The confirmatory test for CD is an abnormal small intestine biopsy and a favorable clinical response to a gluten-free diet. The biopsy will show atrophy of the intestinal villi, presence of an abnormally large number of inflammatory cells, and abnormal epithelial cells. A favorable clinical response to a gluten-free diet is the disappearance of symptoms and improvements in health when gluten is completely avoided.

Regarding non-celiac gluten sensitivity, the best confirmation is a positive response to a gluten-free diet.

Importance of Going Gluten-Free

If you have CD, it is extremely important that you consume a gluten-free diet. Merely reducing gluten intake is not good enough. Even small amounts of gluten can initiate the autoimmune response and cause intestinal damage. The gut must be allowed to heal to restore proper nutrient absorption.

Adopting a Gluten-Free Diet

Eliminating gluten-containing grains may leave you thinking, “What can I eat?” But it is very possible, once you learn how to design menus, to eat a nutritious and satisfying diet without those grains and the products made from them. Foods that can be eaten include the following:

  • animal products, such as meats, eggs, and milk products
  • vegetables
  • fruits
  • nuts and seeds
  • non-gluten grains

While gluten-containing grains and products made from them are off limits, acceptable grains and their flours include rice, corn, quinoa, amaranth, buckwheat (which is not related to wheat), millet, and teff. Vitamin Cottage provides a more extensive list of non-gluten-containing grains in its Customer Literature Files. Ask a store employee for the “Gluten-Free Grains” handout.

Avoiding gluten is not particularly difficult with a whole foods diet. (For more information, see Vitamin Cottage’s Customer Literature File titled “Natural Foods for Optimal Health.”) However, if you eat processed foods, you must be very vigilant, since gluten can be hidden in ingredients with non-specific names, such as “modified food starch”, “flour”, “cereal”, or “hydrolyzed vegetable protein” (HVP). Gluten may also be contained in additives in the categories of “stabilizer,” “flavoring,” or “emulsifier.”  When you see no obvious gluten source (such as “wheat flour”) on the label but the product is not labeled “gluten-free,” do not assume that it is gluten-free. When in doubt, call the manufacturer.

The Vitamin Cottage Customer Literature Files have a listing of gluten-free products compiled by the Denver Metro Chapter of the Celiac Sprue Association (CSA). This handout also has an extensive list of ingredients that may contain gluten. CSA periodically updates its list of manufacturers and products and publishes those updates on their website: www.geocities.com/csadenver17. CSA, incidentally, serves as a support group for persons with CD, providing information and food ideas at its bimonthly meetings.

To assist in delicious and satisfying gluten-free eating, there are many cookbooks with gluten-free recipes available at Vitamin Cottage and elsewhere.

Further Reading

The Gluten Connection by Shari Lieberman

Going Against the Grain by Melissa Diane Smith

Dangerous Grains by James Braly, M.D. and Ron Hoggan

Celiac Disease, A Hidden Epidemic by Peter H.R. Green, M.D. and Rory Jones

Cookbooks

Gluten Free 101 by Carol Fenster

The Gluten-Free Gourmet series by Bette Hagman

Gluten-Free Without Rice by Nicolette Dumke

Magazine

Living Without, A Lifestyle Guide for People with Allergies and Food Sensitivities


References

[1] “What is gluten sensitivity and how is it diagnosed?” EnteroLab website, 2007,  https://www.enterolab.com/StaticPages/Frame_Faq.htm#gluten_sensitivity

[2] Fass N. Enhanced Testing for Gluten and Food Sensitivity: An interview with Aristo Vojdani. Townsend Letter. January 2013.

[3] Kharrazian D. What type of gluten intolerance do you have? Dr.KNews.com. January 11, 2011. Available at: http://thyroidbook.com/blog/category/cyrex-labs/page/2/