Celiac Disease and Non-Celiac Gluten Sensitivity

Celiac disease is an autoimmune disorder in which the immune system attacks cells of the small intestine when it is exposed to gluten. It is thought that about 1% of the population in North America is affected by celiac disease, and risk factors include family history, certain genetic conditions such as Down syndrome, as well as the presence of other autoimmune conditions such as type 1 diabetes.^[1]

The diagnosis of celiac disease has been fraught with controversy. While there are several blood tests available, including tissue transglutaminase IgA (tTG), patients often go undiagnosed because the appropriate tests are not ordered. “Classic” symptoms of celiac are commonly thought of as including severe diarrhea and abdominal pain; when these symptoms are absent, many physicians fail to consider the diagnosis. It is now known, based on extensive research, that symptoms may be relatively mild in many—if not most—cases. In addition to blood testing, the gold standard in the diagnosis of celiac disease is endoscopy and biopsy of the small intestine; villous atrophy, or a flattening of the intestinal lining (villi), is the hallmark of active celiac.^[2]

Symptoms may include gastrointestinal manifestations such as diarrhea, constipation, pain, bloating, as well as multisystem manifestations such as iron-deficiency anemia refractory to iron supplementation, other nutrient deficiencies due to poor absorption, weight loss or poor growth in children, bone loss, a characteristic skin rash called dermatitis herpetiformis, fatty liver, and unexplained infertility, among others.^[2][3]

A recent study reviewed the metabolic and nutritional status of patients with celiac disease.^[3] Patients with celiac are at higher risk of iron, folic acid, B-⁠vitamin, vitamin D, and calcium deficiencies.^[3] One study found that patients with celiac disease who had been on a strict gluten-free diet for several years experienced improvements in metabolic parameters as well as mood scores in association with vitamin B–complex supplementation.^[4] Plasma total homocysteine (tHcy), a marker of B-⁠vitamin deficiency, especially vitamin B₁₂ deficiency, normalized and dropped by 34%, and ratings of anxiety and depression both improved.

The treatment for celiac is adherence to a strict gluten-free diet. Gluten is a protein present in specific grains including wheat, rye, barley, spelt, kamut, couscous, and others. Grains such as rice, quinoa, and oatmeal are gluten-free, if they are not contaminated with gluten within the processing facility, as may sometimes be the case for oats. Gluten and/or wheat products are often used in the creation of many other foods, however, and this makes adherence to a gluten-free diet challenging. Examples of foods that commonly contain gluten include salad dressings, gravies and sauces, canned soups, deli meats and sausages, chocolates and candies, chips, and beer (made from barley). Happily, many gluten-free options are becoming available.

In addition to celiac disease, a new entity named non-⁠celiac gluten enteropathy or non-⁠celiac gluten sensitivity (NCGS) has been identified. As the name suggests, this is a disorder characterized by gluten intolerance, where however testing for celiac disease remains negative. A broad range of symptoms may be affected by this type of intolerance, most notably conditions of chronic pain such as muscle and joint pain, migraine, and fibromyalgia. In the course of naturopathic medical practice, we routinely observe associations with a range of inflammatory and/or autoimmune conditions such as rheumatoid arthritis, lupus, and other arthrides; Hashimoto’s thyroiditis; inflammatory bowel disease; irritable bowel syndrome; and a host of skin conditions.^[5][6][7]

Individuals who suspect a form of gluten reactivity should consult a knowledgeable health-care provider who can assist them in conducting a thorough evaluation.

References

1. John M. Eisenberg Center for Clinical Decisions and Communications Science. Diagnosis of Celiac Disease: Current State of the Evidence. Rockville (MD): Agency for Healthcare Research and Quality (US), 2007, 262 pages. Available at https://www.effectivehealthcare.ahrq.gov/ehc/products/574/2175/celiac-disease-report-160129.pdf
2. Kochhar, G.S., et al. “Celiac disease: Managing a multisystem disorder.” Cleveland Clinic Journal of Medicine. Vol. 83, No. 3 (2016): 217–227.
3. Abenavoli, L., et al. “Nutritional profile of adult patients with celiac disease.” European Review for Medical and Pharmacological Sciences. Vol. 19, No. 22 (2015): 4285–4292.
4. Hallert, C., et al. “Clinical trial: B vitamins improve health in patients with coeliac disease living on a gluten-free diet.” Alimentary Pharmacology & Therapeutics. Vol. 29, No. 8 (2009): 811–816.
5. Zanwar, V.G., et al. “Symptomatic improvement with gluten restriction in irritable bowel syndrome: A prospective, randomized, double blinded placebo controlled trial.” Intestinal Research. Vol. 14, No. 4 (2016): 343–350.
6. Bonciolini, V., et al. “Cutaneous manifestations of non-celiac gluten sensitivity: Clinical histological and immunopathological features.” Nutrients. Vol. 7, No. 9 (2015): 7798–7805.
7. Isasi, C., E. Tejerina, and L.M. Morán. “Non-celiac gluten sensitivity and rheumatic diseases.” Reumatología Clinica. Vol. 12, No. 1 (2016): 4–10.