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celiac disease vs gluten sensitivity



Over the last decade, gluten free eating has become more and more popular. I have witnessed the eye-rolling that occurs at a table when someone asks for a gluten free menu and I have been privy to this stigma more so than usual as my mom has had celiac disease for the past 10 years.


I have tried to explain the pathophysiology (what goes wrong in your body) to my family so many times… But I know exactly how my brother thinks of it:


“When I eat dairy, I don’t feel well. But it tastes good so it’s worth it. So, it must be the same thing”


I love my brother to pieces (in case you’re reading this Ty) but… this statement is not only incorrect, it also doesn’t acknowledge or appreciate the severity of a condition such as celiac disease.


Let’s end the stigma once and for all! Please read below as I differentiate between a gluten sensitivity and celiac disease.



Celiac Disease

Celiac disease is an autoimmune disorder. The other autoimmune diseases you may be aware of include Crohn’s, Colitis, Lupus, Rheumatoid Arthritis, MS, Hashimoto's and more.


When we breakdown the word autoimmune:

Auto in the medical dictionary means self, while immune means the development of antibodies and other immune cells. Therefore, auto-immunity is the process of creating antibodies and immune cells AGAINST our own self.


In terms of celiac, this auto-immunity occurs in the gut – more specifically the small intestine. Our small intestine is in charge of not only digesting our food but also absorbing the resulting nutrients. To help with this, in the small intestine we have something called villi & microvilli. These are projections (hills and valleys) that bud out from the gut lining. Their role is to increase the area that can interact with the contents of our gut and absorb its nutrients. Think of it this way:

  • Picture a desert (mostly flat) vs the Rockies (endless mountains). What do the mountains add? A whole lot more surface area... the villi & microvilli in our gut do the same.


Now we understand the importance of these villi & microvilli – allowing us to absorb WAY more nutrients.


What happens in celiac?

In Celiac disease, there is an immune reaction to a part of gluten called gliadin. Gliadin is a protein of wheat and other grains including barley and rye. Gliadin crosses the gut lining and causes an immune response. The immune cells and antibodies created are little but mighty and they usually attack foreign bodies including bacteria and viruses. In celiac they attack our OWN gut lining.


Specifically, our villi & microvilli leading to something called villous atrophy. Without our villi & microvilli we can only absorb a fraction of what we should be…


Why do we eat in the first place… because we are hungry! But also because we need the nutrients. If we didn’t need nutrients we would all eat donuts and drink wine all day.


Imagine eating a healthy, well balanced diet but being unable to actually absorb anything you are eating… we would all feel like crap.


The only way to regrow these villi & microvilli is to stop eating gluten, to prevent our immune system from attacking the gut lining and giving our villi & microvilli a chance to regrow.


How long does it take for these villi & microvilli to regrow? Anywhere from days, weeks, months to years.


Now….


Let’s talk about why (1,2):

Celiac has been linked to environmental and genetic causes. For example, if you have a first degree relative with celiac disease you have a 10-15% change of developing it.

There are 2 main genes that they have found linked to celiac: HLA-DQ2 and HLA-DQ8. Meaning, if you inherit these genes you have an increased risk of celiac disease. Studies done on twins show that these HLA genes contribute to less than a 50% risk of celiac disease.


If you have another autoimmune disease, your chance of developing celiac is also increased by around 5%.


There are also environmental effects including:

  • A protective effect of breast-feeding

  • Increased risk if a child is exposed to gluten before 4 months old

  • Gut infections


Who?

Celiac affects ~1% of the population and it is thought that many people are undiagnosed.

Unfortunately, it affects 2-3x more women than mena common theme in autoimmune disease.

It used to be thought that Celiac disease did not develop in childhood and only adults had it. Studies are now finding that this is not true.


Symptoms:

Most patients report chronic diarrhea, weight loss and abdominal discomfort. Instead of diarrhea, patients could also experience constipation. The more systemic symptoms include iron deficiency anemia (because the gut can’t absorb iron), osteoporosis and malabsorption. There is also a rash connected to Celiac disease called dermatitis herpetiformis.


Diagnosis:

There is a blood test called the anti-TTG test that checks if your blood contains antibodies relating to celiac disease. However, in order for this to work, you must be eating gluten at the time of the test. The gold standard is a duodenal biopsy that shows signs including white blood cells in the gut lining, and a flat gut lining (villous atrophy - the loss of those villi & microvilli I was talking about).


Treatment:

A Strict Gluten Free Diet!!!

Once diagnosed the patient will be required to stay on a gluten free diet, which is much easier in today’s world. The positive part about the diagnosis is that doctors will be able to monitor vitamin and mineral deficiencies and aim for proper absorption.


Complications:

The reason why celiac disease is so important is not only for absorption purposes (as discussed above) but also because it has been linked to cancer of the small intestine and lymphatic system. It is also associated with complications such as infertility and loss of pregnancy. In addition, it can lead to various neurologic disorders.


Now that we understand the importance of Celiac Disease we can discuss Gluten Sensitivity.



Gluten Sensitivity

Many years ago, the medical system started to notice that a gluten sensitivity could occur without celiac disease and that distinguishing the two via a diagnosis was key.


Gluten sensitivity is characterized by adverse symptoms after the ingestion of gluten in patients that do not have:

  1. Celiac disease

  2. Wheat allergy

This is what we call a diagnosis of exclusion. To understand this here is a scenario:

A young woman goes to see her doctor complaining of diarrhea, bloating and fatigue after eating gluten. Although there are MANY different diagnoses possible, let’s say the doctor limited it down to 3:

  1. Gluten sensitivity

  2. Wheat allergy - this is an IgE reaction (similar to a peanut allergy) in which wheat intake can lead to breathing difficulties, hives and abdominal pain.

  3. Celiac disease

The doctor is not able to tell this patient she has a gluten sensitivity until he completely eliminates the possibility that she has a wheat allergy or celiac disease. This could include a blood test for celiac disease and an allergy test for wheat. That is why the other name for it is NCGS – Non Celiac Gluten Sensitivity


Symptoms:

They are very similar to IBS like symptoms and can be divided by intestinal (in the gut) and extra-intestinal (outside the gut).

Intestinal symptoms include: abdominal pain, bloating, constipation or diarrhea

Extra-intestinal symptoms include: brain fog, headache, fatigue, joint pain, skin rash, depression and anxiety.


These symptoms occur soon after we eat gluten and should disappear when we remove gluten from our diet (hours to days).


Why?

They aren’t really sure yet but it could be due to leaky gut (increased permeability of the GI tract).


Solution:

Gluten free diet!



Based on the information provided above, gluten sensitivity is very much so a thing and not just a “fad” as many people think. It is also crucial to know the difference between Celiac Disease and Gluten Sensitivity so that they can be diagnosed and treated appropriately.


Now we can go ahead and educate those people (like my brother) that shake their head when someone asks for a gluten free menu.


Sources:

  1. Green, P. H., & Cellier, C. (2007). Celiac disease. New england journal of medicine, 357(17), 1731-1743.

  2. Fasano, A., & Catassi, C. (2012). Celiac disease. New England Journal of Medicine, 367(25), 2419-2426.

  3. Dieterich, W., Ehnis, T., Bauer, M., Donner, P., Volta, U., Riecken, E. O., & Schuppan, D. (1997). Identification of tissue transglutaminase as the autoantigen of celiac disease. Nature medicine, 3(7), 797.

  4. Schuppan, D. (2000). Current concepts of celiac disease pathogenesis. Gastroenterology, 119(1), 234-242.

  5. Catassi, C., Bai, J. C., Bonaz, B., Bouma, G., Calabrò, A., Carroccio, A., ... & Francavilla, R. (2013). Non-celiac gluten sensitivity: the new frontier of gluten related disorders. Nutrients, 5(10), 3839-3853.

  6. Lebwohl, B., Ludvigsson, J. F., & Green, P. H. (2015). Celiac disease and non-celiac gluten sensitivity. Bmj, 351, h4347.

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