Celiac Disease, Gluten Allergy, and Gluten Intolerance
Gluten is a protein found in wheat and other grains such as barley and rye. Celiac disease, gluten allergy, gluten sensitivity, gluten intolerance, and wheat allergy are all terms that describe reactions to wheat and other gluten grains. It is estimated that 15-30% of people are allergic or intolerant to gluten. A brief description of the different terms follows:
Celiac disease is the most severe form of gluten intolerance and it is a genetic disease. While active disease is not present at birth, at some point during one’s life about 4% of individuals who are genetically susceptible develop active celiac disease for reasons that are not understood. About 15% of people with a parent with celiac disease will develop celiac disease themselves. The small intestine, in particular, can suffer extensive damage that decreases the absorptive ability of this organ leading to malnutrition. Although most people think of celiac as a gastrointestinal disease, an estimated 87% of people with celiac disease experience symptoms exclusively outside the gut. The most common extra-intestinal symptoms are neurological (about ½ of people with celiac develop neuropathy) and immunological, including a 10 times higher risk of developing autoimmune disease. Individuals with celiac disease must strictly avoid gluten for the rest of their life. True celiac disease affects less than 1% of the population.
Gluten intolerance, also called gluten sensitivity, is the most common form of gluten reaction, affecting 15-30% of the population. It is less severe than celiac disease, because it doesn’t cause the intestinal damage associated with celiac disease, but it shares many of the same symptoms as celiac disease and can still cause significant harm. It is not necessarily a life-long disease – many of these people are able to reintroduce gluten with appropriate treatment.
Wheat allergy is an allergic reaction to wheat only, not the gluten portion of wheat and not to other gluten grains. It can cause the same symptoms as gluten intolerance and also responds to treatment. It is relatively rare, in my experience, for this allergy to occur without a corresponding gluten allergy.
Gluten is found in the following grains and grain products: durum, semolina, spelt, kamut, malt, couscous, bulgur, triticale, einkorn, faro, and sometimes oats.
The following grains and flours are gluten-free: amaranth, arrowroot, buckwheat, corn, legume flours, mesquite flour, millet, nut flours, potato, quinoa, rice, sago, sorghum, tapioca, taro, and teff.
The most common symptoms of celiac disease, gluten intolerance, and wheat allergy include the following:
- Irritable bowel
- Ear infections
- Abdominal pain
In addition to all of the above, celiac disease can also cause:
- Dermatitis herpetiformis (a skin condition)
- Sjogren’s syndrome
- Diabetes, type 1
- Addison’s disease
Testing for gluten allergy
Testing for celiac disease and gluten intolerance requires different tests, but both can generally be diagnosed with a simple blood test.
Celiac disease can usually be diagnosed with a blood test for anti-tissue transglutaminase antibody (IgA). This test is positive in about 90% of people with celiac disease. It is made more accurate with the addition of a total IgA level to rule out a false negative from immune deficiency. Other tests that are sometimes used, but are less sensitive, include anti-endomyseal antibody and anti-gliadin antibody. All of these tests are only reliably accurate if an individual is eating gluten. For those who have been on a gluten free diet, genetic testing is also available, but this test cannot determine whether an individual has active celiac disease.
The gold standard for celiac disease testing is a biopsy of the small intestine, which is done during endoscopy. This test is much more invasive and expensive than a blood test, but since about 15% of people with biopsy proven celiac disease can have negative blood results, it should be considered for those who are symptomatic and have negative blood tests.
Gluten intolerance can be diagnosed with a simple blood test for antibodies to gluten and other foods. Typically a panel of 10-150 foods is tested. While gluten alone can be tested, most people with a gluten allergy will also be allergic to other foods as well, so I recommend testing a full panel of foods. Click here for more information on food allergy testing. Technically gluten intolerance is not a true allergy and cannot be determined with this type of testing. In my experience, however, the vast majority of people who believe or have been told they have gluten intolerance or gluten sensitivity actually have a non-celiac gluten allergy and will test positive with this type of testing. In practice, therefore, these terms can be used interchangeably.
Wheat allergy can be determined with the same test used for gluten intolerance.
Avoidance – First and foremost, the most important treatment for any form of gluten allergy is avoidance. A single exposure to gluten in someone with celiac disease can produce an inflammatory reaction that can last 3 months. While lifelong avoidance is necessary for those with celiac disease, individuals with gluten intolerance and wheat allergy can generally reintroduce gluten after 6-24 months with appropriate treatment. Most people with gluten intolerance can also generally tolerate small amounts of gluten in the diet without having a severe reaction.
Other treatment strategies for both celiac disease and gluten intolerance include the following:
Heal the gut and the liver – Most people will feel much better very quickly after eliminating gluten (although some individuals can take one month or longer to respond). Simply eliminating gluten, however, doesn’t address the cause of gluten intolerance. In the case of celiac disease, studies have shown that a clinical response to a gluten free diet doesn’t correlate to healing the damaged lining of the small intestine. Only 34% of people with celiac disease have a completely healed small intestine lining after 2 years on a gluten free diet. The gut and the liver are the organs most greatly impacted by celiac disease and gluten intolerance. Examples of things that can heal the gut and the liver include:
- Quercetin – a bioflavanoid (plant extract) that reduces inflammation and allergic reactions in the gut
- Glutamine – an amino acid (protein component) that heals the damaged intestinal lining
- Milk thistle – an herbal medicine that is very effective at protecting and restoring liver function
- Beneficial bacteria – help to reduce allergic reactions in the gut and improve overall gut health. This can be in the form of probiotics (actual bacteria) or prebiotics (substances such as the vegetable fiber inulin that promote the growth of beneficial bacteria).
Look for other allergens – As mentioned previously, most people with celiac disease or gluten intolerance will be allergic to other foods as well, particularly dairy in the case of celiac disease. It is very important to identify and eliminate these other allergens to allow the gut to heal.
Address malnutrition – Most people with celiac disease suffer from malnutrition because the damaged small intestine lining is not able to properly absorb nutrients. Simple testing for some nutrients is widely available, such as iron, folate, and vitamins D and B12. Other nutrients, such as the important minerals calcium and magnesium, cannot be easily measured with a simple blood test because these levels are maintained by taking these minerals from the bone. Most people with a calcium or magnesium deficiency will therefore have normal blood levels of these two minerals. Some specialty testing is available to more fully assess nutrient status. I recommend that all people with celiac disease take a high potency multiple vitamin-mineral supplement.
Click here for more information on food allergies.
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