Gluten Intolerance & Celiac Disease
Celiac Disease (CD), also called Gluten Enteropathy, has until recently been known as Gluten Intolerance.
CD is a hereditary disorder of the immune system in which eating gluten leads to damage of the lining of the small intestine. This results in mal-absorption of nutrients and vitamins.
CD is the result of IgA and IgG antibody responses to gluten.
It is important to differentiate between CD, mediated by IgA and IgG antibodies, and wheat allergy, which is mediated by IgE antibodies.
In people with celiac disease, consumption of gluten, a major protein in wheat, rye, and barley products, causes inflammation and damage to the lining of the small intestine, resulting in diarrhea, mal-absorption, fat in the stool, and nutritional and vitamin deficiencies.
Quite simply, if you suffer from Celiac disease you have a genetic disorder that makes you intolerant to gluten.
Celiac disease can affect all types of people. However, it seems to be more prevalent among people of Northern European descent.
In the USA about 1 in 133 people suffer from Celiac disease.
Celiac disease also goes by the names gluten-sensitive enteropathy, nontropical sprue, and celiac sprue.
Many people blame wheat, found in most of the grain-based products for causing their abdominal pain, gas, bloating and diarrhea.
"But more likely, gluten is what’s irritating your gut," says Leslie Bonci, MPH, RD, author of the American Dietetic Association Guide to Better Digestion.
What is gluten?
Gluten is the elastic, rubbery protein present in wheat, rye, barley and to a lesser degree in oats. It binds the dough in foods such as bread and other baked goods. It contributes to spongy consistency. Rice and maize do not contain gluten.
However, gluten is only one protein found in wheat, rye and barley. These foods, like all other foods, contain a number of discreet proteins that all can result in adverse reactions, including allergies.
For example, wheat protein comprises 4 main groups of proteins: water-soluble, salt-soluble, alcohol-soluble and alcohol-insoluble. The major proteins in wheat-albumin, globulin, gliadin and glutenin (gluten)-vary in proportion according to the type of wheat.
Gluten, the protein found in wheat, rye, and barley, is the common denominator in most of the grain-based products we eat, such as cereals, breads, and pasta.
Simple gluten intolerance can be uncomfortable, but the symptoms are fleeting. The good news is that gluten intolerance is not a food allergy, and eating gluten does not usually cause damage – unless you have Celiac Disease.
The inability to sufficiently digest gluten protein can lead to all sorts of symptoms, including skin rashes, irritability, aggression, moodiness, ‘brain fog,’ cognitive problems, cramping, bowel problems, pain, and sleep disturbances.
More serious gluten intolerance is called celiac disease. That’s when gluten actually triggers the body’s immune system. When people with celiac disease eat foods or use products containing gluten, their immune system responds by damaging the villi — tiny, fingerlike projections in the small intestine that absorb the nutrients from food. For this reason it’s considered an autoimmune disease.
What are the complications of celiac disease?
Damage to the small intestine and the resulting nutrient absorption problems put a person with celiac disease at risk for malnutrition, anemia, and several other diseases and health problems.
Lymphoma and adenocarcinoma are cancers that can develop in the intestine.
Osteoporosis is a condition in which the bones become weak, brittle, and prone to breaking. Poor calcium absorption contributes to osteoporosis.
Miscarriage and congenital malformation of the baby, such as neural tube defects, are risks for pregnant women with untreated celiac disease because of nutrient absorption problems.
Short stature refers to being significantly under the average height. Short stature results when childhood celiac disease prevents nutrient absorption during the years when nutrition is critical to a child’s normal growth and development. Children who are diagnosed and treated before their growth stops may have a catch-up period.
How common is Celiac Disease?
Celiac Disease is one of the commonest life-long disorders in Western countries. CD is frequently under-diagnosed, particularly in adults, who may present with subtle symptoms. In some countries the incidence is as high as 1 in 200 (Sweden) or 1 in 10,000 (Denmark). The incidence in South Africa has not been ascertained, but is thought to be low, although the disease is most probably under-diagnosed.
What are the symptoms of Celiac Disease?
Typically, CD presents at the age of 6-24 months with symptoms of intestinal mal-absorption, impaired growth, abnormal stools, abdominal distension, muscle wasting, poor muscle tone (hypotonia), poor appetite or irritability, following the introduction of cereals into the diet.
In adults, the symptoms of CD may be quite varied, from severe weight loss and diarrhea and bulky, offensive stools to subtle complaints of cramps, abdominal bloating, flatulence and even constipation. These individuals are often mistakenly diagnosed as having Irritable Bowel Syndrome. Recent studies show that some individuals with CD present with no symptom but a form of ataxia. Recurrent oral aphthous ulcers are common and should arouse suspicion of the condition. Other symptoms may include persistent iron-deficiency anemia, folate deficiency anemia or a calcium metabolism disturbance.
Dermatitis herpetiformis is a variant of Celiac Disease in which clusters of itchy blisters occur, usually over the buttocks, knees and elbows.
Doctors must have a low threshold of suspicion when seeing patients with symptoms such as those described above.
There are various blood tests that can be used to support the diagnosis of CD.
- The anti-gliadin antibody (AGA) assay, which measures the amount of IgA and IgG antibody produced against the gliadin component of cereals.
- The anti-reticulin antibody (ARA) test, in which IgG antibodies are viewed in an immuno-fluorescent microscope examination.
- The anti-endomysial antibody (AEA) assay, which identifies IgA antibodies against the endomysium tissue.
These tests offer simple and fast tools to investigate patients with suspected CD. They are particularly recommended for screening relatives of CD patients or patients who are affected by a related disease such as Malabsorption or Diabetes Mellitus, and for monitoring the compliance to a gluten-free diet.
None of these tests has shown 100% accuracy, and a small-intestinal mucosal biopsy remains the cornerstone for diagnosis. Any provisional diagnosis of Celiac Disease must be confirmed by this biopsy. The procedure is safe and usually performed at the time of gastrointestinal endoscopy.
Treatment of Celiac Disease
Medication is ineffective in treating this condition. The only treatment available is the complete removal of gluten from the diet. This usually entails life-long avoidance of all cereals containing gluten, including wheat, oats, rye and barley. Individuals on any avoidance diet are at risk of developing deficiencies of micro-nutrients (e.g., thiamine, riboflavin,