What is gluten and why are so many people avoiding it?
How do I know if I am gluten sensitive?
Is Celiac Disease and Gluten Sensitivity the same thing?
What are the most common manifestations of gluten sensitivity and Celiac Disease?
OK, so lets have an honest discussion about gluten, why eliminating gluten may alleviate so many health issues, the “red flags” of gluten sensitivity and why it is more important to avoid gluten today than ever before.
First, what is gluten?:
Gluten is a mixture of proteins found in all grains. It has two primary subfractions: prolamines (Gliadin is a prolamine found in wheat) and glutelins.
In wheat, 69% of protein is Gliadin which is why it is the most detrimental of all the grains, but this was not always the case. In fact, ancient wheat (the wheat of our forefathers) has only 5% of its protein as Gliadin. Why the change? Genetic Modification. The fluffy white processed bread of today is nothing like its ancient, dense, fibrous, non-genetically modified cousin. In another article I will discuss the issues with genetically modified foods, but for now, let’s continue our discussion of gluten.
Gluten sensitivity is simply an inflammatory reaction in the body to gluten. Gluten intolerance and gluten sensitivity are two separate diagnoses. Gluten intolerance is called Celiac Disease, an autoimmune disorder in which the immune system attacts the body’s own tissues. Celiac Disease arises from exposure to gluten, and leads to chronic intestinal damage and inflammation and a long list of clinical signs and symptoms. Celiac Disease and gluten sensitivity cause local disruptions of nutrient absorption in the intestine.
For example, disruption of iron absorption is a common symptom of gluten intolerance. Intolerance often causes anemia, poor folate uptake, and can lead to a variety of neurological problems. Gluten sensitivity is often less obvious and symptoms vary from person to person, making it hard to diagnose.
The most common signs and symptoms of gluten sensitivity are:
*Digestive Issues
*Chronic Fatigue
*Anemia
*Short stature
*Epilepsy
*Dementia
*Joint pain, etc.
Again, the gliadin in wheat is the most serious offender, but ALL grains have some form of gluten.
In fact, a study in Clinical and Experimental Allergy (25(11), Nov 1995, pages 1100-1107) indicates that caution should be used in all grains.
The reason that gluten sensitivity is difficult to diagnose via a simple allergy test (RAST test [radioallergosorbent test] or skin prick test) and is often missed by allergists/immunologists is because gluten sensitivity can cause a myriad of reactions including IgE mediated, immune-complex, or delayed hypersensitivity reactions. RAST and skin prick tests only test for IgE mediated reactions.
THE AVERAGE TIME TO DIAGNOSE CELIAC DISEASE IS 8-11 YEARS and 5 PHYSICIANS.
By the time most celiac disease is diagnosed, CNS (central nervous system) effects have likely already begun to occur. 28% of celiacs showed OCD (obsessive compulsive) symptoms and many celiac patients have anxiety. There is a positive correlation of gluten intolerance and depressive symptoms.
A summary outlining the mechanism of disease is well outlined in Scientific American (“Surprises from Celiac Disease,” 301(2), August 2009, pg 54-61): There is a wonderful diagram that I recommend viewing here.
In brief:
- Indigestible fragments of gluten induce enterocytes to release the protein zonulin, which loosens tight junctions.
- Gluten fragments cross the intestinal lining in abundance and accumulate under epithelial cells (enterocytes).
- Gluten induces enterocytes to secrete interleukin-15 (IL-15), which arouses immune cells called intraepithelial lymphocytes against enterocytes.
- Tissue transglutaminase (TTG), an enzyme released by the damaged cells, modifies the gluten.(Note, TTG is a laboratory test you can request from your physician, more on this below)
- Antigen-presenting cells of the immune system join the modified gluten to HLA molecules and display to other immune cells called helper T cells.
- Helper T cells recognize the complex and secrete molecules that attract other immune cells which can directly damage enterocytes. Helper T cells also spur killer T cells to directly attack enterocytes.
- B cells release antibody molecules targeted to gluten and TTG. All these various assaults disable and kill enterocytes.
Diagnosis:
Historically, the classic gold standard for diagnosing Celiac Disease (gluten intolerance) was a biopsy obtained endoscopically, however that is starting to change. Today there are many new, accurate and less invasive tests.
A comprehensive approach to gluten intolerance/sensitivity is necessary, including a thorough clinical exam, history, serology, and genetics.
The major CD-predisposing genes are HLA-DQ2 (about 90% of patients) and/or HLA-DQ8 (about 10% of patients). Either HLA DQ2 or DQ8 was detected in every early-developing Celiac patient.
Serum IgA endomysial and transglutaminase 2 antibodies are starting tools in diagnosing Celiac Disease. However, the predictive value at onset is only 50-60%. However, if a patient carries the HLA-DQ2 or DQ8 antigents, the PPV (positive predictive value) of the autoantibodies (indicating an autoimmune reaction and therefore Celiac Disease) approaches 100%.
In Summary:
The true gold standard to test for gluten sensitivity is to eliminate gluten completely and monitor symptoms.
Serum studies include IgA and IgG transglutaminase and deaminated gliadin, with a predictive value of 50-60%.
Genetic testing for HLA-DQ2 or DQ8 is highly accurate.
For my patients who suffer with chronic “red flags” such as digestive issues, anemia, joint pain, etc., I recommend a complete gluten elimination for at least 3 months, although it could take up to 6 months to really feel a difference. It is also important to eat medicinal foods and take supplements to replete the body with nutrient and vitamin deficiencies which are a hallmark of the gut permeability associated with gluten intolerance and sensitivity.
There are also very accurate stool tests that may be ordered through functional medicine laboratories.
A few interesting findings about autoimmune disease:
Research has shown that many autoimmune diseases, including Celiac Disease, Type 1 Diabetes, Multiple Sclerosis, Rheumatoid Arthritis and Inflammatory Bowel Disease, all have increased intestinal permeability caused by an abnormally high level of zonulin. In Celiac Disease, it is gluten itself that promps exaggerated zonulin secretion, but the instigating factor of other diseases is still largely unknown.
A new page on the optimal diet, the benefits and best ways to go gluten free, what should be on your grocery list, and how to fit this in your budget are soon to come.