Gluten Intolerance and Celiac Disease

By George J Georgiou

Celiac disease, also known as gluten intolerance, is a genetic disorder that affects 1 in 133 (11). Americans. Symptoms of celiac disease can range from the classic features, such as diarrhoea, weight loss, and malnutrition, to latent symptoms such as isolated nutrient deficiencies but no gastrointestinal symptoms. The disease mostly affects people of European descent, and may occur more rarely in black and Asian populations (13). Those affected suffer damage to the villi (shortening and villous flattening) in the lamina propria and crypt regions of their intestines when they eat specific food-grain antigens (toxic amino acid sequences) that are found in wheat, rye, and barley (13). Oats have traditionally been considered to be toxic to celiacs, but recent scientific studies have shown otherwise. This research is ongoing, however, and it may be too early to draw solid conclusions.

Because of the broad range of symptoms celiac disease presents, it can be difficult to diagnose. The symptoms can range from "mild weakness, bone pain, and aphthous stomatitis to chronic diarrhoea, abdominal bloating, and progressive weight loss (13)." If a person with the disorder continues to eat gluten, studies have shown that he or she will increase their chances of gastrointestinal cancer by a factor of 40 to 100 times that of the normal population (14). Further, "gastrointestinal carcinoma or lymphoma develops in up to 15 percent of patients with untreated or refractory celiac disease (13)." It is therefore imperative that the disease is quickly and properly diagnosed so it can be treated as soon as possible.

Based on the figure mentioned above we can extrapolate the total number of people in the United States with celiac disease: 2,131,019 (based on the total population: 283,425,607 (15). It is very important that doctors understand just how many people have this disease so that routine testing for it is done to bring the diagnosis rate in line with the disease's epidemiology. Testing is fairly simple and involves screening the patient's blood for antigliadin (AGA) and endomysium antibodies (EmA), and/or doing a biopsy on the areas of the intestines mentioned above, which is still the standard for a formal diagnosis.
The only acceptable treatment for celiac disease is strict adherence to a 100% gluten-free diet for life. An adherence to a gluten-free diet can prevent almost all complications caused by the disease (13). A gluten-free diet means avoiding all products that contain wheat, rye and barley, or any of their derivatives. This is a difficult task as there are many hidden sources of gluten found in the ingredients of many processed foods.

In the Lancet recently (1) a consistent cohort of patients affected by drug-resistant epilepsy with cerebral calcifications where all cured when they were placed on a gluten-free diet. All had an atrophic jejunal mucosa, which recovered on a gluten free diet. Gluten intolerance is now a recognized cause of brain calcifications and epilepsy, of dementia, of psychiatric disturbances: many researchers believe that, in genetically predisposed subjects, gluten is not healthy for the brain function (2).

On the other end of the spectrum, we know that there are many gluten intolerant people that do not manifest any complaints even though they have a flat intestinal mucosa (3). It is considered that about 0.3 - 1 percent of the population are gluten intolerant and react with a wide spectrum of symptoms from no apparent reaction to severe life-threatening diseases.

WHAT IS GLUTEN INTOLERANCE

Celiac disease (CD) also referred to as gluten sensitive enteropathy (GSE), gluten intolerance, or celiac sprue. It is considered to be the most under-diagnosed common disease today, affecting 1in every 170 to 250 people in the USA. It is a chronic, inherited disease, and if untreated can ultimately lead to malnutrition. Gluten intolerance is the result

of an autoimmune system response to the ingestion of gluten (from wheat, rye, and barley) that damages the small intestine. Nutrients then quickly passed through the small intestine, rather than being absorbed. To develop celiac disease (CD) three (3) things must be present: 1) you must inherit the gene, 2) consume gluten, and 3) have the gene triggered. Common triggers include stress, trauma (surgeries, pregnancy, etc.), and viral infections. Approximately 10% of first-degree relatives could have CD triggered in their lifetime. The disease is permanent and damage to the small intestine will occur every time you consume gluten, regardless if symptoms are present.
This intolerance is strongly linked to specific genetic markers which have evolved over thousands of years, along with environmental and dietary changes that have occurred over the last century or so.

TREATMENT

Dietitians developed the following dietary guidelines, for the Gluten Intolerance Group® and Celiac Disease Foundation. These are in agreement with the Gluten Free Diet guidelines published by the American Dietetic Association, October 2000. The American Dietetic Association Guidelines were written through a cooperative effort of dietitian experts in celiac disease in Canada and the United States.

The following grains & starches are allowed:
· Buckwheat
· Rice
· Corn
· Potato
· Tapioca
· Bean
· Sorghum
· Soy
· Arrowroot
· Amaranth
· Quinoa
· Millet
· Tef
· Nut Flours

The following grains contain gluten and are not allowed:
· Wheat (durum, semolina)
· Rye
· Barley
· Spelt
· Triticale
· Kamut
· Farina

The following ingredients are questionable and should not be consumed unless you can verify they do not contain or are derived from prohibited grains:
· Brown rice syrup (frequently made with barley)
· Caramel color
· Dextrin (usually corn, but may be derived from wheat)
· Flour or cereal products
· Hydrolyzed vegetable protein (HVP), vegetable protein, hydrolyzed plant protein (HPP), or textured vegetable protein (TVP)
· Malt or malt flavoring (usually made from barley. Okay if made from corn)
· Modified food starch or modified starch
· Mono- & di-glycerides (in dry products only)
· Natural and artificial flavors
· Soy sauce or soy sauce solids (many soy sauces contain wheat)

Additional components frequently overlooked that often contain gluten:
· Breading
· Broth
· Coating mixes
· Communion Wafers
· Croutons
· Imitation bacon
· Imitation seafood
· Marinades
· Pastas
· Processed Meats
· Roux
· Sauces
· Self-basting poultry
· Soup base
· Stuffing
· Thickeners
Can I Use Oats?

Based on numerous studies in the last several years, involving children and adults, using pure oats and store-shelf oats, around the world; research shows that oats do not appear to be harmful to persons with gluten intolerance in moderation. Recent discovery of the specific reactive peptide in gluten intolerance and research by Dr. Don Kasarda on the amino acid sequencing of oats vs. the now known peptide, would again clear oats as not having the reactive peptide sequence known to be problematic for gluten intolerance. Therefore oats are gluten free.

However, there is concern by the medical and research communities worldwide that the level of possible contamination of oats with gluten from unacceptable sources is too high. Therefore, GIG® is not recommending the use of oats by the celiac community.

Today, as we know and understand research on gluten intolerance, the offending cereals that must be avoided are wheat, rye, barley and their derivative cereals.

REFERENCES
1. Gobbi G, Bouquet F, Greco L, Lambertini A, Tassinari CA, Ventura A, Zaniboni MG: "Coeliac Disease, epilepsy and cerebral calcifications" Lancet, 340, Nx 8817, 439-443, 1992

2. Epilepsy and other neurological disorders in Coeliac Disease. Republic of S. Marino Meeting, April 10-12 1995, G. Gobbi edt., Raven Press, in preparation.

3. Catassi C, Ratsch IM, Fabiani E, Rossini M, Bordicchia F, Candela F, Coppa GV, Giorgi PL: Coeliac Disease in the year 2000: exploring the iceberg. Lancet, 1994, 343: 200-203.

4. Furon R. Manuel de Prehistorie Generale., 1958, Payor, Paris.

5. Raven PH, Evert RF, Eichorn S Biology of plants. 4th ed. Worth Publ. Inc, New York, 1986.

6. Feldman M, Sears ER The wild gene resources of wheat. Scientific American, 1981: 98-109.

7. Lucio Giunio Moderato Columella " Libri rei rusticae" Anni 60-65 dopo Cristo. Ed. Einaudi,1977.

8. Greco,L.: " Malnutrizione di classe a Napoli" Inchiesta, 24, 53-63, 1976.

9. Maki M, Kallonen K, Landeaho ML, Visakorpi JK.:Changing pattern of childhood coeliac disease in Finland. Acta Paediatr Scand 1988; 77:408-412.

10. Greco L, Maki M, Di Donato F, Visakorpi JK. Epidemiology of Coeliac Disease in Europe and the Mediterranean area. A summary report on the Multicentric study by the European Society of Paediatric Gastroenterology and Nutrition. In "Common Food Intolerances 1: Epidemiology of Coeliac Disease", Auricchio S, Visakorpi JK, editors, Karger, Basel, 1992, pp 14-24.

11. Alessio Fasano, MD, et. al., Arch Intern Med. 2003;163:286-292
12. Gastroenterology, April, 1996 "First Epidemiological Study of Gluten Intolerance in the United States." By Karoly Horvath, MD, Ph.D., et. al..
13. New England Journal of Medicine, May 2, 1996 -- Volume 334, Number 18, "The Many Faces of Celiac Disease" by Charles H. Halsted, MD
14. Goggins, et. al. "Celiac Disease and Other Nutrient Related Injuries to the Gastrointestinal Tract" The American Journal of Gastroenterology. Vol. 89, No. 8, pages S2 - S13, 1994.
15. United States Census Bureau, January 7, 2001.

By Dr. George J Georgiou