What is Gluten-Associated Medical Problems?
Gluten has gained a lot of attention in recent years, both in the medical field and in popular media. There’s a lot of information out there, some of it can be confusing or misleading. This article will discuss the health conditions associated with gluten based on confirmed medical facts.
Gluten is a type of protein found in certain grains, including wheat, barley, rye, oat, and their products such as malt. It helps dough rise and gives bread its fluffy and chewy texture. Around 80% of the protein in wheat bread is gluten. Pasta contains a smaller amount of gluten. Gluten can also be found in imitation meats, beer, soy sauce, and occasionally in other food products like ice cream and ketchup. It’s also commonly found in certain hair products and cosmetics.
For doctors, gluten is significant because it can cause various health problems, including celiac disease, non-celiac gluten sensitivity, wheat or grain allergy, gluten ataxia, and a skin condition called dermatitis herpetiformis.
History of Gluten-Related Disorders
The concept of a gluten-related disorder was first described in 250 AD by Aretaeus Cappadocia, using the Greek term ‘koiliakos’, which referred to abdomen-related diseases. Samuel Gee, in 1888, was one of the first to link this disorder to diet, stating that treatment primarily consisted of food regulation.
In 1908, Carnegie Brown published about peripheral neuritis, a neurological disorder, observed in patients with celiac disease. However, diagnoses weren’t always reliable at the time.
Interestingly, during World War II, when many people were suffering from malnutrition, patients with celiac disease showed improvement due to lack of wheat in their diet. The rise in disease incidence after the war suggested the role of wheat in causing celiac disease.
Medical advancements of the 1950s and 1960s allowed for more definite diagnoses of celiac disease. It was in this period that the scientific community distinguished celiac disease as an autoimmune disorder rather than a food allergy. The disease was also found to be linked with certain genetic markers and other neurological disorders.
Fast-forward to the 1980s, the term “non-celiac gluten sensitivity” was introduced. At first, it was thought to be more prevalent in Europe than the United States, but further studies found it to be equally common in the U.S. Further research throughout the 2000s and 2010s linked gluten to a host of health issues.
Due to these findings, the Food and Drug Administration (FDA) in 2013 started requiring the labeling of gluten-free products. This led to a significant rise in the global gluten-free industry, which is expected to be worth $4.7 billion by 2020.
What Causes Gluten-Associated Medical Problems?
CD, also known as Celiac disease, occurs when you have sensitivity to gluten. Gluten is a protein found in wheat, barley, and rye. When you eat gluten, changes happen in your intestines that can be reversed if you avoid eating gluten.
Non-celiac gluten sensitivity (NCGS) is a term used when people have symptoms caused by eating gluten but don’t have celiac disease or wheat allergy. Symptoms can affect the intestines or occur elsewhere in the body and usually improve when you stop eating gluten-containing grains. The exact cause of non-celiac gluten sensitivity is not yet known.
This condition is also referred to as “non-celiac wheat sensitivity” and is likely the most common gluten-related issue. It affects somewhere between 0.5% and 13% of people. There are no specific tests to confirm the condition. As a result, celiac disease and wheat allergies need to be ruled out first. Many people with this condition experience symptoms similar to irritable bowel syndrome (IBS) for years. The symptoms often improve when they start a gluten-free diet.
In people with NCGS, certain carbohydrates called FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) in gluten-containing grains may cause their symptoms. FODMAPs can cause mild wheat intolerance, generally causing only digestive issues.
Gluten ataxia is another condition related to gluten sensitivity. It’s not entirely clear how it happens, but it is believed antibodies may affect a part of the brain called the cerebellum causing damage. Gluten ataxia is more common in some hereditary ataxia syndromes than in general, and a gluten-free diet can benefit some of these patients and reduce neurological deficits. However, it’s not universally helpful. Sometimes, the damage is already done and cannot be reversed, causing to shrinkage and degeneration of the cerebellum.
Dermatitis herpetiformis (DH) is a skin condition linked to gluten sensitivity and celiac disease. It’s a less common condition and is characterized by intensely itchy and inflamed bumps and blisters, often seen on the forearms, knees, scalp, or buttocks.
Risk Factors and Frequency for Gluten-Associated Medical Problems
Celiac disease is a condition that most often affects people of Northern European descent between the ages of 10 and 40. Recently, thanks to better diagnostic methods, more cases are being identified, with the current rate estimated to be between 1 in 70 and 1 in 300. If people are screened for the disease, it can lead to identification and treatment of unnoticed nutrient deficiencies and minor symptoms. It can also potentially lower the risk of developing certain cancers. However, the disease requires a strict diet that can lower a person’s quality of life, especially if they do not have symptoms.
Gluten ataxia is another condition that usually begins to affect people in their 50s or 60s.
- The disease known as Dermatitis Herpetiformis (DH), on the other hand, is becoming less common possibly due to the increased identification and treatment of Celiac Disease.
- It’s not common in children but is most frequently seen in people in their 40s and 50s.
- Men are more likely to have this disease than women.
Signs and Symptoms of Gluten-Associated Medical Problems
Celiac disease is a health condition caused by an immune reaction to eating gluten, a protein found in wheat, barley, and rye. There are two types: classic and atypical celiac disease. Classic celiac disease involves issues like poor nutrient absorption, weight loss, diarrhea, fatty stools, nutrient or vitamin deficiencies, and positive antibodies. Additionally, there’s damage to the small intestine – a range of severity from mild irritation to severe damage; and yet, the degree of damage does not correlate to symptom severity.
- Poor nutrient absorption
- Weight loss
- Diarrhea
- Fatty stools
- Nutrient or vitamin deficiencies
- Damage to the small intestine
On the other hand, atypical celiac disease presents with less digestive symptoms. The primary concerns are anemia, dental enamel defects, osteoporosis due to vitamin D and calcium deficiencies, arthritis, fertility problems, abnormal liver function tests, and neurological issues due to vitamin B deficiencies. Some people with celiac disease may have no symptoms at all. Doctors have noticed a shift from classical celiac disease in children to atypical presentations in adults, likely due to changes in diet. Celiac disease carries an increased risk of mortality, making routine screening essential. A gluten-free diet can reduce, but not eliminate, the risk of diseases like lymphoma.
Non-Celiac Gluten Sensitivity (NCGS) is a condition that mimics some celiac disease or irritable bowel syndrome symptoms and even wheat allergy. The main difference is that the typical antibodies and intestinal damages seen in celiac disease are absent in NCGS. NCGS is also associated with allergies to certain foods and preservatives, and lactose intolerance is common.
Wheat allergy can trigger severe reactions, with symptoms appearing anywhere from minutes to hours after wheat ingestion. Gluten ataxia is a neurological disorder associated with gluten sensitivity and presents with difficulties with balance and coordination. It slowly develops in middle age or older and involves gait and limb abnormalities and other signs of brain dysfunction. Imaging often shows a shrinkage of the cerebellum, a part of the brain. Other causes of symptoms must be excluded before this diagnosis is confirmed.
Dermatitis Herpetiformis (DH) is an itchy skin condition linked to gluten sensitivity. Symptoms include grouped blisters and bumps at different stages of development, particularly on the elbows and forearms. Although these usually heal without scarring, they may leave a change in skin color. Oral lesions and enamel defects can also occur. Despite significant small intestine damage that aligns with celiac disease, few of these patients have gastrointestinal symptoms. This discrepancy is because the autoimmune response primarily impacts the skin rather than the digestive tract in DH.
Testing for Gluten-Associated Medical Problems
Tests for celiac disease, a disorder where the consumption of gluten harms the small intestine, are recommended for specific groups of people. These groups include people experiencing stomach-related issues like chronic diarrhea, weight loss, excessive wind, and bloating. Testing may also be needed for those experiencing symptoms unrelated to the stomach, such as anemia, vitamin deficiencies, issues with liver function, stunted growth, frequent fetal loss, mouth sores, numbness in limbs, or balance problems. Trait testing should also be considered for close relatives of people with celiac disease.
All these tests must be carried out while the person is still consuming gluten. An IgA anti-tissue transglutaminase test is usually used after the age of two, although an IgA endomysial assay is an alternative. The endomysial antibodies target the tissue surrounding smooth muscle cells. If there’s an IgA deficiency, which is more common in people with celiac disease, then a test called an IgG-deaminated gliadin peptides test is used. Not all tests should be performed though, for example, the Antigliadin test has low predictive value and should be avoided.
If the test is positive and celiac disease is likely, a small bowel biopsy may be needed. This is a procedure where a small piece of tissue is taken from your small bowel and then examined. Findings can vary, but there are specific methods to highlight areas of damage. Video imaging might show features of celiac disease and could negate the need for a biopsy. If symptoms, serology (blood test results), and pathology (changes caused by disease) are consistent and the symptoms and pathology clear up with a gluten-free diet, the diagnosis is confirmed. If there’s still uncertainty regarding the diagnosis after these steps, genetic tests may be required. A negative result would rule out celiac disease. Occasionally, people may need to resume consuming gluten to confirm the diagnosis.
Non-celiac gluten sensitivity is diagnosed clinically, mainly by process of elimination. People with this condition test negative for celiac disease in their laboratory and endoscopy results, but their symptoms improve significantly after they stop eating gluten. Healthcare providers may ask patients to use a symptom severity scale and maintain a food diary to track symptom improvement when gluten is removed from the diet.
Wheat allergy is typically diagnosed through an oral food challenge, supervised by a healthcare provider, although an open challenge often suffices. Tests measuring grain-specific IgE (a type of antibody that triggers allergic reactions) can support this diagnosis. Skin prick tests or in vitro tests for IgE are often done before food challenges.
Dermatitis herpetiformis (DH), an itchy, blistering skin condition that’s a form of celiac disease, is diagnosed through symptoms, blood tests, tissue pathology, and direct immunofluorescence microscopy (a technique that uses fluorescent dyes to visualize and analyze tissue). Immunofluorescence microscopy is considered the best diagnostic tool, with a 92% positivity in DH cases. The biopsy should be taken from next-to-normal looking skin, as biopsies taken from affected skin can yield falsely negative results.
Treatment Options for Gluten-Associated Medical Problems
For individuals diagnosed with celiac disease or CD, the prescribed treatment is to follow a gluten-free diet. This means avoiding foods that contain gluten, a protein found in wheat, rye, barley, as well as in certain alcoholic drinks like beers, ales, lagers, and malt vinegar. Safe alternatives include distilled alcoholic beverages, wine vinegar, potatoes, corn, rice, and soybeans. Some individuals might also have to avoid dairy if they suffer from lactose intolerance. Paying attention to food labels will help with this.
Adhering to a strict gluten-free diet can be hard, but it’s crucial to avoid certain health risks like nutrient deficiencies and increased chance of cancer associated with celiac disease. Since everyone’s tolerance to gluten and their body’s response to it varies, it’s important to monitor the person’s reaction to the diet through medical check-ups, blood tests, and sometimes tissue samples (biopsies). Those whose symptoms or positive blood test results persist after two years on a gluten-free diet are considered non-responders. This can happen if they’re unable to stick to the diet or have accidentally consumed gluten. Some non-responders may need to be treated with medications like prednisone, azathioprine, 6-mercaptopurine, or mycophenolate in severe cases. If treatment fails to work, it could suggest the development of stomach and intestinal cancers or lymphomas. In such scenarios, nutritional deficiencies will need to be addressed and supplements provided.
The same gluten-free diet also applies to treating non-celiac gluten sensitivity (NCGS).
Those with a wheat allergy should stay away from wheat and find substitutes that provide the same nutrients. These can come in the form of other grain or non-grain sources. If they have a severe allergy that causes an immediate and potentially life-threatening reaction (known as an IgE-mediated reaction), it’s essential to have an epinephrine pen on hand.
Dermatitis herpetiformis or DH, a skin condition closely associated with celiac disease, can be managed with a gluten-free diet and, in the short term, a medication called dapsone. Dapsone helps to relieve itching within 72 hours of starting the treatment and causes skin lesions to clear up in a few days. However, it has side effects like hypersensitivity, hemolysis (destruction of red blood cells, especially in individuals with a genetic condition called G6PD deficiency), and agranulocytosis (a serious reduction in a type of white blood cells). Regular blood tests, including ones to check liver and kidney function, are recommended when taking this medication. Three months into the treatment, if a gluten-free diet has been maintained, slow reductions in the dapsone dosage can be attempted. If taking dapsone isn’t possible, other sulfa drugs or topical steroids, which help reduce itching, can be used. However, it’s worth noting that systemic steroids, which are delivered throughout the body, aren’t effective for this condition.
What else can Gluten-Associated Medical Problems be?
When discussing enteric symptoms similar to Celiac Disease (CD), various other health conditions come into play. These include:
- Irritable bowel syndrome
- Lactose intolerance
- Non-Celiac Gluten Sensitivity (NCGS)
- Wheat allergy
- Crohn’s disease
- Ulcerative colitis
- Intestinal infections
- Bacterial overgrowth
For skin-related symptoms akin to Dermatitis Herpetiformis (DH), which is connected to Celiac Disease, some other conditions could be the cause. These include:
- Atopic dermatitis (a type of skin inflammation)
- Scabies (a skin infection caused by mites)
- Itchy insect bites
- Bullous pemphigoid (a skin disease that causes blisters)
- IgA bullous dermatosis (a rare skin disorder marked by blisters)
What to expect with Gluten-Associated Medical Problems
CD, or celiac disease, is a chronic condition that a person will have their entire life. However, it’s not as dismal as it sounds. Nowadays, we have better ways of diagnosing it and more options for treatment compared to a few decades ago. Most people with celiac disease find relief from symptoms through a gluten-free diet. However, it’s also important to note that there have been cases where people with long-term celiac disease have developed stomach and gastrointestinal cancers.
DH, also known as Dermatitis Herpetiformis, is another chronic, life-long condition, just like celiac disease. People with Dermatitis Herpetiformis need to follow a gluten-free diet and take a medication called dapsone to manage their symptoms. Although it sounds severe, it’s not as serious as it seems because few individuals are able to successfully cease these treatments permanently. The good news is that Dermatitis Herpetiformis doesn’t increase the risk of death like celiac disease does. This is presumably because dermatitis herpetiformis affects the skin and not the gastrointestinal tract. In fact, some studies have even suggested that people with dermatitis herpetiformis have a lower risk of death.
Possible Complications When Diagnosed with Gluten-Associated Medical Problems
While there are complications, they don’t occur often. The disease itself is the main problem.[43]
In regards to Gluten Ataxia, sometimes a gluten-free diet isn’t enough. The damage to the cerebellum, a part of the brain, can become permanent, causing it to shrink and deteriorate.
