doctor's orders: a gluten-free diet is the treatment for celiac disease
8 minute read
the cause of celiac disease is gluten, which is a group of proteins in grains like wheat, rye and barley. getty
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celiac disease is a lifelong condition that is more common than you might realize, affecting as many as one per cent of the population, according to celiac canada. the numbers could relate to growing awareness, earlier diagnosis and excellent blood screening tests, although experts say it’s a tricky condition to diagnose because symptoms can be vague and suggest other health issues.
the cause of celiac disease is gluten, which is a group of proteins in grains like wheat, rye and barley, that — for those in the one per cent — makes it difficult for the small intestine to absorb vitamins and other nutrients. it’s an inherited condition, but symptoms can develop at any age after ingesting gluten.
healthing spoke with dr. vipul jairath, a gastroenterologist and clinical researcher at london health sciences centre university hospital in london, ont. and a professor of medicine at western university, about how to recognize the symptoms of celiac disease, why diet is so critical and the importance of annual checkups.
what is celiac disease?
dr. jairath: celiac disease is what we call an autoimmune disorder, and it predominantly affects the small bowel — the small intestine where we absorb most of our nutrients. it’s caused by the ingestion of gluten in people who have genetic susceptibility to developing celiac disease. gluten is the major protein that we find in wheat, rye, and barley. celiac disease is slightly more common in females than males.
when the disease process starts, like any autoimmune condition, your body starts to attack the small intestine. it’s the part of the bowel where we really absorb all of our good nutrients, vitamins and iron. the small bowel is made of these tiny fingers called villi — there are billions of them. they look like fingers under a microscope and they provide the surface area by which we absorb nutrients, vitamins and so on. when your autoimmune process starts to damage the small bowel, those finger-like projections start to flatten and become blunted, so they no longer have the absorption surface area. that’s what drives some of the symptoms of celiac disease and what we call malabsorption. if you don’t have the ability to absorb those things, you can develop deficiencies in vitamin d, iron and other vitamins.
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gluten-intolerant but you don’t have celiac disease
it’s also important to note that people can be intolerant to gluten but not have celiac disease. gluten intolerance and the nature of some foods like bread cause some people to experience bloating. some of those food substances that contain gluten are fermentable products that can lead to excess gas production, bloating and discomfort. some people just naturally find that they have less of those symptoms when they reduce gluten in their diet. there are no negative effects to wheat and gluten, but there are genuinely people who have unpleasant gastrointestinal symptoms. if you choose a gluten-free lifestyle, it’s important to have a well-balanced diet and make sure you are getting all your essential nutrients.
what are the signs of celiac disease?
dr. j.: you can get gastrointestinal symptoms, which are symptoms coming from the gut. you can also get signs and symptoms from outside of the gut. sometimes they can be quite mild and, therefore, it can take a long time to get a diagnosis. on average, individuals could have symptoms for seven to nine years before they actually get a diagnosis of celiac disease. the common gastrointestinal symptoms are things like diarrhea — loose bowel movements, abdominal pain, bloating and constipation. those are the classical symptoms, but these can also be attributed to any number of digestive ailments.
dr. vipul jairath, a gastroenterologist and clinical researcher at london health sciences centre university hospital in london, ont. and a professor of medicine at western university, says it can take seven to nine years to get a celiac disease diagnosis. supplied
for symptoms and signs outside of the gut, celiac disease can affect other organs, such as the skin, so sometimes it causes skin manifestations like rashes.
if you can’t absorb all the goodies and nutrients, you might develop anemia, for example, or iron deficiency anemia that can present with fatigue and tiredness and concentration difficulties. in some circumstances, when you don’t absorb vitamin d, that can cause thinning of the bones and an increased risk of fractures.
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how is celiac disease diagnosed?
dr. j.: if you have non-specific gastrointestinal symptoms of bloating or occasional pain or diarrhea, most often this gets put down to, ‘it might just be a bug, or you could have irritable bowel.’ the way to diagnose celiac disease is a blood test for a specific enzyme called ttg. it’s a test that can be done by your family physician or a gastroenterologist, if you are referred to one. but the gold standard in adults is to do the blood test and then an endoscopy into the small intestine and take biopsies of the small bowel.
how do people develop celiac disease? what are the risk factors?
dr. j.: we don’t know why people develop celiac disease. we know that the combination of a genetic predisposition and eating gluten causes it, but there are unknown environmental triggers that lead to the condition itself. there are lots of theories around what they might be, like infections in the gut that can predispose someone to celiac disease, or it could be the actual amount and type of gluten. it could also be changes in the microbes in the gut.
the good news is that we know the offending agent is gluten and the treatment of celiac disease is a gluten-free diet. the vast majority of people will improve and become asymptomatic and not be at risk of complications when they go onta strict gluten-free diet. the bad news is that it is difficult because gluten is found in wheat and all the things related to wheat — so rye, barley and the derivatives of that, flour, and pasta — gluten is in many, many things. the downside is that making these changes can have a big impact on lifestyle impact, causing negative psychosocial effects and impair quality of life.
most people will see complete resolution of symptoms within six months of following a gluten-free diet. there is a very small proportion of individuals with celiac disease — less than four per cent — who, despite being on a strict gluten-free diet, can continue to have symptoms and inflammation in the bowel. but the vast majority will have complete resolution of symptoms and also improve their underlying issues, like anemia.
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other than a gluten-free diet, what are other treatments?
dr. j.: the first thing is the gluten-free diet, and it’s really important that the person is connected with a dietitian who is familiar with celiac disease because they can help navigate the key components of a gluten-free diet. they would also ensure eating habits are addressed, that there’s a balanced diet, and both the macro and micro nutrients are addressed.
then we would do a full blood panel to make sure there’s no anemia present or vitamin d deficiency. the other thing would be a general bone density check. a bone scan will see if there’s any thinning of the bones, either early thinning or established thinning of the bones. if it shows early thinning of the bones, a gluten-free diet and other lifestyle choices will help prevent further damage, like supplementation of vitamin d and calcium, physical activity, not smoking. we would recheck again in three or five years. if you saw somebody with established osteoporosis — advanced thinning of the bones — then we may refer them to a bone specialist and there might be specific medications given for osteoporosis.
there are a number of drug treatments for celiac disease in the very early stages of testing that come from the recognition that a gluten-free diet is imperfect because it’s a major lifestyle change. treatments might break down those gluten enzymes, for example, or they might protect the bowel itself from becoming damaged. but these will be many years in development before we know if they work.
tell me more about the social impact of celiac disease?
dr. j.: the social impact is huge. dining out, for example, or even eating at school or the workplace — there’s always a risk of inadvertent gluten exposure. for some people, a small amount of gluten exposure might not make any difference, but sometimes people will say, ‘i know when i’ve had a small amount because i will get symptoms within hours.’ they’re very clear that they had an inadvertent contamination or ate something they shouldn’t have eaten. the other thing is the natural steps in the food processing chain can lead to exposure to gluten. for gluten-free oats and lentils, we know that during processing they naturally might get some sort of cross-contamination, so making food choices can be challenging. but if you go into mainstream supermarkets today, gluten-free products are much more accessible and visible. if you’ve got up to one per cent of the population with celiac disease, that’s a lot of people who require gluten-free products. i think it’s positive that we’re seeing greater accessibility.
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what’s one piece of advice for someone with celiac disease?
dr. j.: the first thing is reassurance since it’s overwhelming initially because there’s a major lifestyle change needed. i reassure people by saying that we know what’s driving the disease, this ingestion of gluten, and there’s a very high likelihood that you will have complete resolution of your symptoms and damage in the bowel by going on a gluten-free diet — and that that will also prevent complications of the disease later. it’s also important to have the appropriate support. making sure you are connected with a dietitian and have regular followups with a specialist to ensure you are not deficient in any nutrients.
i think reassurance is really important in this situation and having access to resources through celiac patient organizations and other communities that provide information. and if you have persistent symptoms or changing symptoms, it’s really important that you go back and see a specialist for further investigation, because again, a very small proportion of people will have celiac disease that is refractory (resistant to treatment).
for more information about celiac disease, visit celiac canada or the canadian celiac association.
karen hawthorne is a toronto-based writer.
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