Celiac disease (gluten-sensitive enteropathy), sometimes called sprue or celiac, is an immune reaction to eating gluten, a protein found in wheat, barley, and rye. The self-diagnosis of this condition and over-diagnosis can be a problem. Celiac disease affects about 1 out of every 100 individuals; people with a first-degree relative with celiac disease (parent, child, sibling) have a 1 in 10 risk of developing the condition.
Celiac disease can be defined as a small bowel disorder characterized by mucosal inflammation, villous atrophy, and crypt hyperplasia, which occur upon exposure to dietary gluten and which demonstrate improvement after withdrawal of gluten from the diet. Over-diagnosis of celiac disease or a complete removal of all gluten in patients who do not have celiac may have consequences.
In the Nurses’ Health Study II, researchers investigated individual grain-containing foods and whole and refined grain intake during adolescence, early adulthood, and premenopausal years in relation to breast cancer risk. The outcome proposes that high whole grain food intake may be responsible for lower breast cancer risk before menopause, while fiber in whole grain foods may mediate the association with whole grains. Grains are an important part of a healthy diet. A good source of healthy carbohydrates, various vitamins and minerals, and fiber. They are also naturally low in fat.
Some people experience symptoms found in celiac disease, such as abdominal pain, bloating, diarrhea, constipation, headaches, bone or joint pain, and chronic fatigue when they have gluten in their diet, yet do not test positive for celiac disease. There are recent studies with this group of individuals and when blinded to their diet ingredients, their symptoms did not often correlate with the gluten intake in their diet. We need to continue to research the patients we describe as having non-celiac gluten sensitivity and non-celiac wheat sensitivity. That is a condition, when removing gluten from the diet, appears to resolve symptoms.
Who should be tested for celiac disease?
Testing for celiac disease should be considered in the following groups of patients:
• Those with gastrointestinal symptoms including chronic or recurrent diarrhea, malabsorption, weight loss, and abdominal distension or bloating. This includes patients with symptoms suggestive of irritable bowel syndrome or severe lactose intolerance.
• Individuals without other explanations for signs and symptoms such as iron deficiency anemia, folate, or vitamin B12 deficiency, persistent elevation in serum liver function tests, delayed puberty, recurrent fetal loss, low birth weight infants, reduced fertility, persistent aphthous stomatitis, peripheral neuropathy without a known cause, or recurrent migraine headaches.
• Patients with type 1 diabetes mellitus and first-degree relatives of individuals with celiac disease if they have signs, symptoms, or laboratory evidence of possible celiac disease. Testing for celiac disease may be considered in asymptomatic first-degree relatives of patients with confirmed diagnosis of celiac disease, particularly children.
There is some debate about screening patients with osteoporosis; currently it is not recommended routinely.
We can test for celiac disease in a variety of way, but our first test is usually done using an antibody called TTG-IgA while the patient is maintained on gluten. If the individual is on a strict gluten-free diet, the test can be misleading, coming up negative even when they are actually afflicted. A biopsy of the lining beyond the stomach in the duodenum is also used to confirm the diagnosis. Genotyping can be helpful, with blood taken to look at the HLA DQ2 and DQ8 genotype.
As a general rule, there are six key elements in the management of patients with celiac disease, summarized with the following acronym:
Consultation with a skilled dietitian.
Education about the disease.
Lifelong adherence to a gluten-free diet.
Identification and treatment of nutritional deficiencies.
Access to an advocacy group.
Continuous long-term follow-up by a multidisciplinary team.
How do you get enough nutrition if we leave out wheat, rye, and barley?
Whole grains are even better for you than wheat, rye and barley, and with celiac disease we continue to recommend whole grains. These include brown, black or wild rice, quinoa, amaranth, pure buckwheat, corn, cornmeal, popcorn, millet, gluten-free oats, sorghum and teff.