Celiac disease, also called coeliac disease, is an autoimmune disease: a disease in which the body produces antibodies that attack its own tissues, leading to the deterioration or destruction of such tissues. (Celiac Disease Foundation, 2017) This is a disease where the small intestine is hypersensitive to gluten. Gluten is a substance present in cereal grains and a mixture of two proteins, which causes illness in people with celiac disease. Gluten is found in wheat, barley, rye, certain oats, malt, maltodextrin, bran, and related grains and their hybrids. People with celiac disease have to avoid ingesting foods with gluten, such as bread, pasta, and pastries. It is a chronic disease, which means that a patient with celiac disease can never grow out of it. One study shows that the amount of patients with celiac disease had more than doubled the amount in the years 2009 to 2012, compared to what it had been the years 1988 to 1994. Celiac disease affects a reported three million Americans, which is one percent of the population. Twenty to thirty percent of the world’s population has been found to carry the gene associated with celiac disease. Ninety seven percent of people in America with celiac disease, however, are undiagnosed. One in 133 people in the United States have celiac disease, but only one in 4,700 people have been diagnosed. Studies have shown that celiac disease is much more common in Caucasians than in other ethnic groups. (Celiac Disease Foundation, 2017)
Causes of Celiac Disease
When a patient with celiac disease ingests a food or substance with gluten in it, the immune system reacts to the gluten in food, damaging the villi that line the small intestine. Villi are the tiny, hair-like projections that line the small intestine. The villi absorb the necessary vitamins, minerals, and other nutrients from the food one eats. If the villi are damaged, the nutrients are not absorbed, no matter how much food is consumed. (CDF, 2017)
If left untreated, celiac disease has many long-term effects. One of those effects is malnutrition from the nutrients that are not absorbed from the villi. Another one is the loss of calcium and density in the bones. There can also be lactose intolerance, which is the inability to ingest lactose, which is a component in milk and other dairy products. Other effects include: depression, infertility and miscarriage, cancer, and various neurological problems. Patients with celiac disease are commonly deficient in nutrients such as fiber, zinc, and vitamin D. They are also usually deficient in protein and calories. (Mayo Clinic, 2016)
There are many things that can be the causes of celiac disease. One of these causes is said to be infant feeding practices. Another cause is gut or gastrointestinal bacteria. Sometimes celiac disease is triggered, or becomes active for the first time, after surgery, pregnancy, childbirth, viral infection, or severe emotional stress. Some gene variations may increase the risk of developing celiac disease, but additional factors may be involved. (Mayo Clinic, 2016)
There are over two hundred symptoms relating to celiac disease; however, a large percentage of patients with celiac disease show little to no symptoms, so diagnosis can be difficult. One of the most major symptoms of celiac disease is pain in the abdomen or joints. Gastrointestinal symptoms include diarrhea, fat in the stool, heartburn, indigestion, nausea, and vomiting. Symptoms that affect the whole body include bone loss, fatigue, and malnutrition. Developmental symptoms include delayed puberty and/or slow growth. Other common symptoms include cramping, skin rash, itching, lactose intolerance, depression, weight loss, low blood count (which is called anemia), and osteoporosis- which is when the bones become fragile from loss of tissue. (Libonati, 2008)
If left untreated for too long, the undiagnosed celiac disease in a patient can cause death. If the lining in a patient’s intestines that is supposed to hold water is damaged, the gut pulls water from the body, extremely dehydrating the patient. Malabsorption of specific nutrients that are vital to a person’s health can lead to certain types of cancer, such as leukemia. If the immune system is weakened, that can allow certain common illnesses such as the flu to become deadly, and common illnesses that are meant to be fought off are not. Also, when the immune system in an untreated celiac disease patient tries unsuccessfully to attack and remove the gluten being regularly consumed, it puts the immune system on a heightened alert, causing the immune system to attack other things in the body. (Moreno 2017)
Diagnosing Celiac Disease
There are two major methods of diagnosing celiac disease. The first method is to order blood tests for screening. The most commonly used blood test for diagnosing celiac disease is called the Tissue Transglutaminase lga antibody test, or the tTGlgA test. For the blood test to be accurate, the patient must be consuming a gluten-containing diet prior to the blood test. Celiac disease is hereditary, which means that it runs in families. People with a parent or other first-degree relative with celiac disease have a one in ten chance of developing celiac disease themselves. Having certain genes, such as the HLA-DQ2 and HLA-DQ8 genes, increase a person’s risk of having celiac disease. (Figure 2) The test will be positive in about ninety eight percent of patients with celiac disease; however, this means that there is still a two percent risk of celiac disease patients who have negative antibody test results. There is also a slight risk of a false positive test result for patients with other autoimmune disorders, such as type one diabetes and rheumatoid arthritis. (Moreno, 2017)
The second method used to diagnose celiac disease in patients, is a biopsy of the small intestine. It is the recommended standard for the diagnosis of celiac disease because it will tell the patient if they have celiac disease or if they have a different gastrointestinal disorder or sensitivity. If a patient’s blood tests are positive, their doctor may suggest an endoscopic biopsy of the small intestine just to make sure they have celiac disease and not another autoimmune disease. During the biopsy of the small intestine, a scope is inserted through the mouth and down into the small intestine to get samples of the tissue lining the small intestine. Samples of the tissue will then be studied under a microscope for damage and inflammation due to celiac disease. If damage and inflammation is found in the sample of tissue taken, then the patient has celiac disease. If a patient with celiac disease is diagnosed at an age between four and twelve years old, their chance of developing another autoimmune condition is around 16.7 percent. If they are diagnosed at an age between twelve and twenty years old, their chance of developing another autoimmune condition is around 27 percent, and if they are diagnosed at an age over twenty years old, their chance of developing another autoimmune condition is around 34 percent. (Smarrazzo, 2017)
There is only one known way to treat celiac disease. No surgery or medication is required in the treatment of celiac disease. The only known treatment of celiac disease is a lifelong gluten-free diet. For patients with celiac disease, this diet will stop symptoms, heal any intestinal damage that has been previously caused by their celiac disease, and prevent further intestinal damage. A gluten-free diet is very effective. Symptoms of celiac disease usually go away within only a few days of starting the diet. Unfortunately, complete healing of the damaged villi could take months or even years, and antibody levels will not return to normal until after a year after starting and maintaining the gluten-free diet. (Celiac Support Association, 2016)
A patient with celiac disease must avoid all foods with gluten, such as most pastas, cereals, and bread products. Foods such as fruits, vegetables, fish, rice, flax seeds, quinoa, risotto, soy, beans, and meats do not contain gluten, so patients with celiac disease can eat any of these foods. There are more than two thousand gluten free food items available in regular grocery stores throughout the United States. Celiacs also have to watch out for foods with traces of gluten, such as in cross contamination. To avoid cross contamination, patients with celiac disease must read all labels on foods for hidden gluten or cross contamination. If a food label reads “may contain traces of gluten” or “made in a factory that also processes gluten,” then the product is not safe for a celiac disease patient to consume. Most regular recipes can be converted to gluten-free recipes with substitute flours made from rice, potato, bean, soy, almonds, corn, or tapioca.
In 2004, the Food Allergen Labeling and Consumer Protection Act was passed, making it a law to properly label foods. The Food Allergen Labeling and Consumer Protection Act states that companies have to tell us, on their labels, if their food contains one of the eight major food allergens, which are: milk, shellfish, fish, eggs, tree nuts, peanuts, soybean, and wheat. This labeling system makes it a lot easier for a patient with celiac disease to determine whether a food is safe for them to eat or not. (FDA, 2004)
In spite of having no other treatments for celiac disease, besides a lifetime gluten-free diet, research is being done to develop treatment options outside of the gluten-free diet. Researchers are trying to develop pills that, when taken directly before a meal that could contain small amounts of gluten, prevent gluten from being toxic to people with celiac disease. There are other pills in development that, when taken with meals that contain some gluten, break down the gluten, making it nontoxic before it reaches the small intestine. There are also drugs in development that will shut down the small intestine’s negative response to gluten. Finally, there are vaccines being developed that would be able to give a patient with celiac disease back the tolerance to gluten that was lost when celiac disease developed. Celiac disease is a lifelong struggle, but there is hope in these developing treatment options for a cure. (Gottlieb, et al., 2015)
“Celiac Disease Screening and Diagnosis.” Celiac Disease Foundation, celiac.org/celiac-disease/understanding-celiac-disease-2/diagnosing-celiac-disease/.
“Celiac Disease Symptoms and Causes.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 17 Aug. 2016, www.mayoclinic.org/diseases-conditions/celiac-disease/symptoms-causes/dxc-20214627.
“Celiac Disease Treatment and Follow Up.” Celiac Disease Foundation, celiac.org/celiac-disease/understanding-celiac-disease-2/treating-celiac-disease/.
Center for Food Safety and Applied Nutrition, Office of Regulatory Affairs. “Allergens – Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA).” www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Allergens/ucm106187.htm.
Gottlieb, et al. “Development of drugs for celiac disease: review of endpoints for Phase 2 and 3 trials” Gastroenterol Rep (Oxf) 2015 May; 3(2): 91–102. Published online 2015 Feb 26. doi:10.1093/gastro/gov006.
Libonati, John. “Yes, You Can Die From Celiac Disease.” Gluten Free Works,glutenfreeworks.com/blog/2008/03/10/yes-you-can-die-from-celiac-disease/.
Moreno, María, et al. “Biomarkers to Monitor Gluten-Free Diet Compliance in Celiac Patients.” Nutrients, vol. 9, no. 1, June 2017, p. 46., doi:10.3390/nu9010046.
Smarrazzo, Andrea, et al. “Diagnosis of celiac disease and applicability of ESPGHAN guidelines in Mediterranean countries: a real life prospective study.” BMC Gastroenterology, vol. 17, no. 1, 2017, doi:10.1186/s12876-017-0577-x.
“Treatment of Celiac Disease.” Celiac Support Association, www.csaceliacs.org/treatment_of_celiac_disease.jsp. “What is Celiac Disease?” Celiac Disease Foundation.
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“Figure 1.” s-media-cache ak0.pinimg.com/originals/cf/46/ed/cf46ed3f348cf030e988eee60150f574.jpg.
“Figure 2.” Genetics and Nutrition, American Dietetic Association and National Genetics Education and Development Centre, 2017, www.nchpeg.org/nutrition/index.php?option=com_content&view=article&id=459&Itemid=56&limitstart=2.