Celiac disease and gluten-free diets are a hot topic. On a recent morning show, a registered dietician was interviewed about these diets. She didn’t like the idea that people were following gluten-free diets and missing out on all of those “HEALTHY WHOLE GRAINS” when they don’t necessarily have celiac disease. She believed that only those with diagnosed celiac need gluten-free diets. She saw things as black or white with no variation of intolerance to gluten in between. That is not my clinical experience.
Rather than think in such absolute terms, think of the need to restrict gluten in accordance with gluten responses that can provoke symptoms and lessen quality of life. At the worst end of the spectrum is celiac disease, actually damaging the gastrointestinal tract, with potentially severe consequences including malabsorption and osteoporosis. Then there are the less severe food intolerances that provoke symptoms such as gluten sensitivity and wheat allergy.
A review of these 3 conditions is in order as they can be confusing. It is important to understand the distinctions.
What is Celiac Disease?
Celiac disease is an autoimmune condition triggered by gluten, a specific protein component of wheat, barley, rye and other grains. The inflammatory and immune response set up by gluten damages the villi in the small intestine. Villi are microscopic projections lining the small intestine that absorb nutrients from the gastrointestinal tract. Over time, the villi are severely damaged, preventing proper absorption and leading to malnutrition and increased permeability of the gut. A leaky gut allows substances to find their way into the blood that don’t belong there. This furthers inflammation, and triggers an immune response. This process in turn often triggers other autoimmune conditions.
Celiac disease occurs in about 1% of the population. Many people are undiagnosed, since symptoms can mimic other conditions. In some people it can take up to ten years for a proper diagnosis to be made. During that time, the untreated celiac can result in severe illness.
Better diagnosis is increasing the numbers of known cases of celiac disease. It is thought that the spreading acceptance of the Western diet, including modern forms of wheat — used in almost everything–is also a contributing factor. For an in-depth and interesting discussion of modern wheat see Dr. William Davis’ book Wheat Belly. Since there is a genetic component to celiac, having a family member with celiac disease should be considered a red flag. In susceptible people, the condition may be triggered by a virus or bacterial infection.
Celiac can be especially devastating in kids. Symptoms can begin as early as six months of age, when cereals are usually recommended. Because of malabsorption and resulting malnutrition, these kids demonstrate failure to thrive. If identified and treated, kids can recover, but may not reach full height. They may also be at an increased risk for lymphoma in the gastrointestinal tract.
Celiac disease in adults can be difficult to diagnose. Many have few or no symptoms in early childhood. Symptoms most commonly begin to develop between age twenty and the mid-forties. Celiac disease is associated with dermatitis herpetiformis, a characteristic rash more common in adults than kids. Other symptoms include osteoporosis, autoimmune conditions such as type 1 diabetes and Sjogren’s syndrome, autoimmune thyroiditis, anemia, abnormal liver function tests and gluten ataxia. Infertility, delayed puberty, miscarriage, frequent infections and depression can also be present. Too, celiac disease is more common in people with Down’s syndrome than in the general population.
Common symptoms of celiac disease include gas, bloating, abdominal pain, weight loss, fatigue, weakness and vomiting (more likely in kids), abnormal bowel movements with diarrhea, fatty and foul-smelling stools or constipation in kids.
Diagnosis of Celiac Disease
The best current testing to diagnose celiac disease involves measuring antibodies to two proteins that find their way into the blood from the small intestine. The leaky, inflamed gut allowed these proteins to pass inappropriately into the bloodstream. Since they don’t belong in the blood, the immune system does its job and makes antibodies against them. They are tTG antibody or tissue transglutaminase IgA and IgG, and EMA or endomesial antibody IgA. If these are positive, celiac disease is highly probable. However, keep in mind that if one has already eaten a strict gluten-free diet for a long time these levels can normalize, causing a false negative result.
There are also genetic marker tests–human leukocyte antigens that indicate a strong genetic tendency to develop celiac disease. Intestinal biopsy of the small intestine via endoscope is often recommended for a final diagnosis if the above antibody blood tests are positive.
An important question needs to be asked: If symptoms and antibodies are present, why look further, since a trial of a gluten-free diet is the necessary next step? Beginning treatment and observation of symptoms can help to confirm the results of the blood test. In some people resolution of symptoms can begin within weeks.
The only treatment for celiac disease is a lifelong gluten-free diet. Because even small amounts can damage the villi, it is important to remove all sources of gluten from the diet. Even if you have already committed to a restricted carb diet, gluten must also be strictly avoided if you have celiac disease. You may have experienced some relief of symptoms from controlling carbs, but gluten may still be present in your diet. It is essential to eliminate all sources of gluten to protect the small intestine from ongoing damage and increasing cancer risk. More on sources of gluten later.
Gluten sensitivity is not celiac disease and does not cause damage to the gut villi. However, it can still be problematic, and responds well to a gluten-free diet. In susceptible people there is an immune response to gliadin, a protein component of gluten. Symptoms can occur hours or even days after exposure. People with positive antibody tests to anti-gliadin antibody IgG and IgA likely have gluten sensitivity, especially if the tTG and EMA antibody tests are negative. Note that many GI specialists ignore elevated anti-gluten antibody tests since they don’t diagnose celiac disease. But by thinking in such absolute terms many people are missed who do not have celiac disease but may benefit from a gluten-free diet. Some estimate that 10% of the population test positive for this immune response. Also note that after months of a gluten-free diet these antibody levels can drop and may give a false negative result.
A gluten elimination diet can be useful as a test to determine symptom relief. Of course, some may say it’s only the placebo effect, but if quality of life and health improves one has nothing to lose. People with gluten sensitivity often have some symptoms similar to those with celiac disease, but they also commonly experience joint pain, mental fogginess, fatigue, depression, diarrhea, rash and eczema and headaches. Gluten sensitivity has been suspected in people with ADD, ADHD, autism and schizophrenia. At The Atkins Center, along with the appropriate level of carbohydrate restriction, a grain free diet was also initiated with these conditions.
Wheat allergy triggers the release of histamine from mast cells and white blood cells. There is usually an IgE immune response that can affect the skin, GI tract and respiratory tract. Wheat is among the top 8 food allergies. Remember that more exposure causes more sensitivity. Since wheat is everywhere and considered “healthy” it is not uncommon to find many people with wheat reactions.
Symptoms are those that one expects with allergy: swelling and itching of the mouth or throat, hives, rhinitis, itchy and watery eyes, or gastrointestinal complaints such as cramps, nausea, vomiting and diarrhea. The reaction can begin within a few minutes to hours after exposure. Diagnosis may be made with IgE blood or skin tests, but these are often inconclusive, since people can be reacting to any number of protein components in wheat.
Wheat allergy can account for a variety of nagging lifestyle-related symptoms. Instead of living on any number of over-the-counter or prescription medications for symptom relief, identify those food offenders in your diet. Chronic allergic response can, over time, stress the adrenal glands, make blood sugar unstable, and even be responsible for cravings for allergy-provoking foods. If these cravings make it difficult for you to resist trigger foods, undermining your control and interfering with your weight loss efforts, all the more reason to address this issue.
At The Atkins Center we saw many people over the years with allergies, chronic GI complaints, inflammatory conditions and autoimmune diseases. Since our treatment plan included controlling carbohydrates, grains were removed. This gave us the opportunity to observe changes in symptoms. For many this was all that was needed. Some patients, especially with symptoms of yeast and mold sensitivities, required an additional yeast free diet for a period of time. For more information about the role of yeast and mold refer to Dr. Atkins New Diet Revolution.
Obesity and Grains
Whether or not you suffer from any of the conditions described above, if you are carrying excess body fat, wheat is an issue, and it must be taken seriously if you want to be leaner and healthier.
The path to weight gain, cravings, hunger and overeating is simple: Foods such as wheat elevate blood sugar causing a secretion of insulin move glucose into the cells and blood sugar from rising too high. Because of the quantity and frequency of carb ingestion, over time the body becomes unable to control blood sugar with normal amounts of insulin. Your cells have become insulin resistant.
Unless carb intake is better controlled, eventually dangerously high levels of insulin will be secreted in an effort to control blood sugar, a state called hyperinsulinism. High insulin damages the body, including blood vessels, liver and kidneys, increasing Alzheimer’s and cancer risk, fat storage, and overall mortality.
The fatter we get the more disordered this process becomes. Not only are high insulin levels damaging, so are high glucose levels. You may not be aware of the danger of high postprandial insulin and glucose levels, but research has demonstrated that one can have a normal fasting glucose but very high glucose and insulin levels after eating.
The risk of type 2 diabetes is high. Insulin-producing cells overwork and ultimately stop making insulin. When this happens, you become an insulin dependent type 2 diabetic.
Blood sugar is usually deranged years before reaching this insulin dependent state. The good news is that this process can be stopped at any stage along the way. In the early stages of type 2 diabetes, the body still has some insulin producing cells. To relieve the burden on those cells and avoid a life-long dependence on insulin injections take action and address an out-of-control carb intake before it is too late, especially if you have a family history of diabetes.
Where’s the Gluten?
Unfortunately, it’s almost everywhere. If you need to avoid gluten, and especially if you have celiac disease, reading labels is a must. This applies not only to food, but also to medications, gum, cosmetics such as lipstick, suntan lotion, baby powder, toothpaste and even toys for kids such as play dough and paints.
Some general points to keep in mind:
- Wheat-free is not always gluten-free.
- Suspect gluten in multi-ingredient products or foods in restaurants and social events.
- Suspect seasonings, thickeners, sauces, malt, food starch items, malted or flavored milk and flavorings. Beer is made from malt, and most contains gluten.
- Oats may contain gluten because of cross-contamination.
- Beware of gluten-free products if you are controlling carbs. Many are still very high-carb, and can sabotage your efforts.
For much more extensive information, including a list of food and non-food sources of gluten, see an excellent article published in the 2008 Practical Gastroenterology journal: Hidden Sources of Gluten by Karen Hlywiak. This article also provides web site links with additional and extensive information for gluten-free living.