by Kerry Potter, MS, RD
Lately, I feel that food allergies and sensitivities are a hot topic in the nutrition world. One food sensitivity, gluten, has really grabbed a lot of attention. It’s the latest hype not only in the medical community, but also in the media. There’s a lot to talk about when it comes to gluten intolerances and sensitivities, so let’s just focus on one aspect. I want to address what Celiac Disease (CD) and gluten intolerances are and how they can be diagnosed, in addition to the areas of an individual’s life gluten intolerance can affect.
Celiac Disease is a genetically inherited autoimmune disorder triggered by the protein gluten found in grains wheat, rye, and barley. Gluten is compromised of the proteins gliadins and glutenins. When a person with CD eats foods comprised of gluten, it triggers an immune response that damages the lining of the small intestine. Persons with Celiac Disease who do not follow a life-long gluten free diet are prone to vitamin and mineral deficiencies, iron-deficiency anemia, and bone disease in the long-term.
The gold standard of testing for CD is an intestinal biopsy, with at least eight tissue samples to increase the odds of sampling inflamed tissue. CD is characterized by an immune response to a specific epitope of the protein gliadin (alpha-gliadin) found in gluten and a specific type of transglutaminase (tTG-2). The blood test for CD only screens for the antibodies to this specific epitope, alpha-gliadin, and tTG-2. However, it is becoming more apparent in recent years that there are several different types of protein and epitopes of gliadin in wheat that people cannot tolerate. These individuals fall under the radar due to a lack of adequate diagnostic testing. These individuals fall into the gluten intolerance category, which is harder to define.
Even though digestive issues are a common symptom for gluten intolerance, research shows that there are many symptoms other than GI distress. Gluten intolerance can affect nearly every tissue in the body, including skin and bones. A strong relationship has even been established in medical literature between gluten sensitivity and the hormones progesterone and estrogen. Surprisingly, it seems that about half of the individuals diagnosed with Celiac disease or gluten intolerance do not have gastrointestinal symptoms at all.
So now we know diagnostic testing for Celiac Disease can lead to a lot of false negatives and excludes a portion of the population who have an immune response to other epitopes besides alpha-gliadin. So how do you know if gluten intolerance is affecting you and your health?
First, let me clarify my opinion. Is gluten the root of all evil? Heck no! I do not believe gluten is the root of all disease and that 100% of the population has CD or a gluten intolerance. From all the research articles I have read, I find some saying anywhere from 1 in 200 in the population might have CD, 30% of the population might have gluten intolerance, or even to the extreme of 1 in 20 people have some kind of gluten intolerance. I feel that research is not conclusive at this time, and there are more subjective opinions out there on the topic versus evidenced based literature. I don’t believe everyone has to jump on the gluten free bandwagon. If you feel healthy, have lots of energy, don’t have any illnesses and are tolerating foods with gluten, then there is likely no reason to cut out gluten, especially if you enjoy foods that contain it. On the other hand, if you are having unexplained GI issues, headaches, hormonal issues, or an autoimmune disease, and you and your doctor haven’t found a successful option to help you feel better even after cutting out caffeine, using the right medication, and not over consuming sugar, then why not discuss the possibility of a gluten intolerance with your doctor? There are many connections between autoimmune diseases and gluten intolerance. Type 1 Diabetes Mellitus and chronic thyroiditis are just the tip of the iceberg.
The best way to determine if you have gluten sensitivity is to first see your doctor for a blood test. If your results come back negative and you still suspect that you have an intolerance to gluten, proceed to the intestinal biopsy (or you could save time by going directly to the biopsy although it is more costly). It is important to note that you must not eliminate gluten before diagnostic testing, as it would result in a false negative result. If diagnostic testing shows you are negative for celiac disease or intestinal inflammation, but you still suspect that you are experiencing adverse reactions from consuming gluten, you can conduct a gluten free challenge. This means removing gluten for a minimum of 30 to 60 days to see if your symptoms improve.
My advice to those planning to follow a gluten free diet to test for symptom relief is to prepare in advance and get all family members or persons living in your household on board. Especially if the person testing for gluten intolerance is a child, it may require the whole family follow a gluten free diet for a few months, at least at home. Not because they might also have a gluten sensitivity, but because sometimes it’s difficult for people to initially implement a gluten free diet and be completely compliant if they are around a lot of products that contain gluten. Keep in mind that those without the intolerance can, and should, continue to eat normally outside the home in order to avoid unnecessarily eliminating foods from the diet.
However, in order to know for certain that you benefit from a gluten free diet, you must be 100% compliant with the diet for the full 60 days. Any consumption of gluten will usually trigger symptoms, which can take another 60 days of being gluten-free to alleviate. When the 60 days are over, reintroduce foods with gluten. If your symptoms disappeared with a gluten-free diet, and reappeared with the reintroduction of gluten, that’s a good indicator that you do not digest those foods well. I am currently in the process of a 60-day gluten free challenge and will keep you posted on my experiences!
Cronin CC, Shanahan F. Insulin-dependent diabetes mellitus and coeliac disease. Lancet 1997; 349: 1096–1097
Hansen D, et al. Clinical benefit of a gluten-free diet in type 1 diabetic children with screening-detected celiac disease: a population-based screening study with 2 years’ follow-up. Diabetes Care. 2006 Nov;29(11):2452-6.
Pazianas M, et al. Calcium absorption and bone mineral density in celiac after long term treatment with gluten-free die and adequate calcium intake. Osteoporos Int. 2005 Jan;16(1):56-63.
Sher, KS, Mayberry, JF. Female fertility, obstetric and gynaecological history in coeliac disease. Digestion. 1994;55(4):243-6.