Until recently, celiac disease has been considered a children's disorder marked only by gastrointestinal (GI) problems. But more and more adults, including those without GI problems, are being diagnosed with this autoimmune disorder, which is trigged by eating wheat, rye and barley. An understanding of the links between celiac disease, also known as celiac sprue, and associated conditions, such as osteoporosis, is helping doctors identify more people with celiac disease.
Worked-up by Wheat
In people who are genetically susceptible to this disorder, celiac disease is triggered by a protein component in wheat called gluten. Similar proteins in rye and barley can also set off celiac disease in this group of people.
"Basically, there is an immune response to the gluten proteins, which eventually leads to inflammation and damage to the villi in the small intestine," explains Armin Adaedini, PhD, an assistant professor of neuroscience at Weill Cornell Medical College of Cornell University. Millions of these finger-like villi line the small intestine and play an important role in absorbing nutrients in food.
It's not exactly clear how the wheat gluten, which never gets fully digested in anyone, enters the lining of the small intestine, provoking the reaction. It may occur when someone has a gastrointestinal infection; GI infections have been found to increase risk of the development of celiac disease in children. (Breastfeeding, however, has been found to protect children from celiac disease.) Once the immune system reacts to the gluten in the gut lining, it produces antibodies that mistakenly attack the lining of the small intestines, contributing to inflammation and the wearing away of the villi.
Not everyone who reacts to wheat has celiac disease, however. People with irritable bowel syndrome, who may have trouble tolerating a lot of grains, may have similar symptoms. And celiac disease should not be confused with a wheat allergy, which will produce allergic reactions that can range from hives and a rash to life-threatening anaphylactic shock.
When Should You Suspect Celiac Disease?
In adults and children, the villi damage caused by celiac disease can lead to symptoms such as abdominal pain, diarrhea, pale, foul-smelling stool, weight loss and weakness. Some people may develop an itchy, blistering rash called dermatitis herpetiformis. And irritability and depression may be seen in people with celiac disease. One reason the celiac disease diagnosis is challenging, however, is that the vague GI symptoms can also be caused by a number of other intestinal conditions, including irritable bowel syndrome, gastric ulcers and Crohn's disease.
Celiac disease can also lead to long-term problems. Because the small intestines are no longer able to absorb needed nutrients from food, over time people can suffer from vitamin and mineral deficiencies. And in children, malabsorption can lead to growth problems.
Health
The one thing about celiac disease that is clear is that it affects people to varying degrees.
"Some people can be critically ill with severe malabsorption, and others can be completely well," says Peter Green, MD, director of the Celiac Disease Center at Columbia University. "So there's an enormous spectrum, and we don't know why one person can nearly die and another person is without symptoms."
Today, more and more people who do not have the "classic" GI symptoms of celiac disease are being diagnosed because they have conditions that arise from nutrient deficiencies. For example, if you don't absorb iron, you may develop anemia, and if you're not absorbing calcium, you might develop the bone thinning disease osteoporosis.
New research confirms that people with osteoporosis are at very high risk for celiac disease and vice versa. A study published in February in the Archives of Internal Medicine found that all patients with osteoporosis should be screened for celiac disease, though the editorial suggested that more research is needed. In the study of 840 people, 12 of 266 participants with osteoporosis and 6 of the 574 people without the disease had celiac disease. In other words, celiac disease occurred in 3.4 percent of people with osteoporosis versus 0.2 percent of people without osteoporosis.
Other people who are now considered at high risk for celiac disease are those with other associated disorders, including hormonal diseases such type 1 diabetes, thyroid disease and some reproductive disorders in women. The connection between celiac disease and these conditions is not well understood, but there may be a genetic link. Certain neurological conditions, such epilepsy, migraine headaches and peripheral neuropathy, which causes tingling in the hands and feet, are also associated with celiac disease for unknown reasons.
Likewise, certain cancers are also somehow linked to celiac disease. For example, people with celiac disease are at increased risk for non-Hodgkin's lymphoma, small-intestine adenocarcinoma and esophageal cancer. A gluten-free diet seems to protect people with celiac disease from these cancers.
Another group at high risk for celiac disease is the first-degree relatives of people with celiac disease. According to National Digestive Diseases Information Clearinghouse, you have a 10 percent chance of having celiac disease if someone if your immediate family has it.
Celiac disease is thought to be most common in Caucasian people, and people of Asian or African origin are considered to be at a lower risk. But Dr. Adaedini observed that celiac disease needs to be studied more carefully in these populations.
Delving into Diagnosis
To detect celiac disease, doctors give a blood test that looks for anti-transglutaminase antibodies or anti-endometrial antibodies, which people with celiac disease produce as part of their autoimmune response to the wheat gluten protein. If the test is positive—or if the test is negative but your symptoms strongly suggest celiac disease—you should undergo an intestinal biopsy, in which a piece of the intestine is removed and studied under the microscope to look for signs of celiac disease-related damage.
But a diagnosis of celiac disease is not final until someone responds well to a gluten-free diet, which reverses villi damage; the diet is currently the only way to treat celiac disease, though some people may go on steroids to reduce inflammation if diet by itself does not improve symptoms. In some cases, people will try a gluten-free diet instead of undergoing an intestinal biopsy. If you go on a gluten-free diet and symptoms subside with 6 to 12 months, you probably have celiac disease.
Getting on the Gluten-free Diet
The gluten-free diet involves avoiding anything that contains wheat, rye or barley, so that includes many pastas, grains and cereals. To obtain carbohydrates, people with celiac disease might substitute with rice, quinoa, corn, buckwheat and potatoes.
Dr. Adaedini warns that wheat gluten may lurk in many foods you would not expect to contain it, such as some salad dressings, yogurt drinks, soy sauces, certain medications, mouthwash and processed foods.
It's not easy to stick with a gluten-free diet, but a dietician can help you plan your meals so that you get relief from most of your symptoms.
"A lot of the problems that are directly related to the damage to the intestine go away," Dr. Adaedini says, "but, currently, it doesn't seem that a gluten-free diet has a big effect on some of the other problems, such as the neurological symptoms, or the associated autoimmune disorders."
Still, if you are suffering from GI discomfort or have an associated condition, getting tested for celiac disease might help your body get the nutrition it needs—and help restore your health.
