Celiac disease -- also known as celiac sprue, gluten-induced enteropathy and nontropical (endemic) sprue -- is an intolerance to gliadin, a gluten protein found in wheat and related grains such as barley and rye. Both an autoimmune and gastrointestinal disorder, celiac specifically affects the villi of the small intestine, leading to the flattening of the mucosa of the organ. The normal mucosa looks like a hilly terrain, small fingerlike projections making humps that come out of the base membrane of the herefore reducing the surface area of the intestine and limiting the body's ability to absorb nutrients. Without these villi, the body has a very difficult time absorbing the nutrients presented by the diet, a problem that may lead to malnourishment in even seemingly healthy people.
History and explanation
The first mention of the disease in historical documents was by Aretaeus the Cappadocean in the second century. Until the late 1800s, however, there was little mention of the disease in medical circles. In 1887, the physician Samuel Gee gave a lecture that led to a sudden burst of interest on the condition. Over the next half-century, scientists searched for the cause of the malady, all of them failing to find that grains aggravated the condition until Willen Dicke in the late 1940s.
According to United State Department of Agriculture research chemist Donald D. Kasarda, people afflicted with celiac disease have a negative response to all grains in the genus Triticeae. Included in this genus are the common grains wheat, barley and rye. Within these grains is the protein gliadin, which has been determined to be what causes the immune response in celiacs.
Despite the connection of wheat products and symptoms, it was not until 1954 that John Paulley, a British physician, was able to take a biopsy of a celiac surgery patient and determined that the actual mucosa of the small intestine was being affected by the consumption of gliadin-containing grains. With this discovery using a piece of live tissue, Paulley was able to discover why the wheat caused so many problems to celiac patients.
Symptoms, risks and co-morbidity
For most celiac patients, the ingestion of gliadin leads to gastrointestinal symptoms such as gas, diarrhea and constipation; this form of celiac disease is 'classic'. For a good number of sufferers, however, the diagnosis is not as easy as this. Especially in America, there are problems with many people having latent, or silent, celiac disease. With symptoms such as fatigue, osteoporosis, mouth sores and even seizures, it is easy to see how people could assume other diseases to be the cause of their problems; because a good number of physicians are unfamiliar with celiac disease, it is very rarely diagnosed. If a physician is able to recognise the symptoms, it is easy to do blood tests to test for certain antigens, though the gold standard for diagnosis is an endoscopy, something many patients are unwilling to go for if there is only a possibility of having a certain disease.
Celiac disease, however, is much more dangerous than many people realise. Although it sounds like the symptoms of the disease are related to hypolactasia -- which, admittedly, has a high rate of co-morbidity -- there are a host of other, more major symptoms and co-morbid diseases. Diabetes mellitus, autoimmune thyroid disease, primary biliary cirrhosis and Sjögren's syndrome have all been tied to celiac disease, and at least ten percent of celiac patients also develop neurological complications such as migraines, depression and even epilepsy and extremely severe illnesses like multiple sclerosis, which is caused by the depletion of the myelin sheath around axons, a fact that suggests that gluten is a neurotoxin. Low folate levels in celiac females are believed to lead to missed periods and miscarriages.
Lastly, because the disease has a negative effect on the spleen, which leads to hyposplenism, sufferers of celiac disease are much more likely to develop illnesses; according to Dr Peter Green, celiacs are ten times more likely to get sick in comparison to people with normal intestines. Another concern for celiacs is the increased chance of developing cancers such as non-Hodgkin's lymphoma, which has a very poor prognosis when the enterological system is involved, and intestinal adenocarcinoma -- both of these can be avoided with treatment of the disorder.
Although previously thought to be an uncommon illness in the United States with approximately 1:6000 people suffering from it, a 2003 study published in the Archives of Internal Medicine has theorised from studying samples of blood from donors to the Red Cross that the prevalence of celiac disease in the United States is actually around 1:133. For those who have family members with celiac disease, this number decreases to 1:22. Considering the fact that most people are unaware that they have the disease despite the fact that it is one of the most common genetic diseases on this planet, this is a very precarious health situation. Regardless of these statistics, celiac disease is not one of the diseases that is identified at birth such as phenylketonuria which only affects one of out nineteen thousand newborns. It is believed that if this screening were initiated, there would be less healthcare funding needed for conditions like diabetes mellitus, which has a co-morbidity of six to eight percent, and Addison's disease, as these disorders share a common genetic basis with celiac disease.
Celiac disease is more common in certain groups including diabetics, premenopausal women, people with osteoporosis and sufferers of both Down syndrome and autism. It is very common in families, so it is very much recommended that the children of families where celiac disease is common do blood serum tests at birth, as the development of active symptoms is believed to be related to the time at which children are exposed to gluten. Because of this connection, it is recommended that children not ingest gluten before the development of the gut barrier around the age of three.
Currently, there is only one treatment for celiac disease: a gluten-free diet. With this diet, all foods containing wheat, barley and rye must be avoided, as should all hybrids and subspecies. For many people, this may seem a formidable task, but it is actually very easy to find safe grains, namely mostly unheard of ones such as amaranth, quinoa, tef and flax. A popular replacement grain is rice, which can be used to make bread, cookies and noodles amongst other things. There continues to be a problem, however, that gluten-free diets do not typically provide enough of certain nutrients including folate, vitamin B6, vitamin B12, calcium, vitamin D, magnesium, fibre, iron, folate, thiamine, riboflavin and niacin, so it is important for celiac patients to work with a dietitian to determine what foods and supplements are the best to consume to keep nutrient intake at safe levels.
There is some question in the medical and celiac communities regarding the use of oats, which affect some celiacs but not others, and there is no set answer despite the numerous studies published on the topic. Many scientists believe that oats by themselves are not a threat to celiac individuals but that because they are processed on shared machinery and grown in common fields with gliadin-containing grains, they pose a risk for celiac patients. If a celiac individual can tolerate oats, it is a very beneficial addition to the diet as oats provide iron, fibre, thiamine and zinc.
- Bell, Sumner, Peter H.R. Green and Martin F. Kagnoff. "American Gastroenterlogical Association Medical Position Statement: Celiac Sprue." Gastroenterology 120 (2001): 1522-1525.
- Brogden, Phyllis. "Grain Toxicity." Message posted to The CELIAC List. http://www.enabling.org/ia/celiac/doc/grains.rtf
- Bushara, Khalafalla O. "Neurological/Psychological Presentation of Celiac Disease: Ataxia, Depression, Neuropathy, Seizures, and Autism." In NIH Consensus Development Conference on Celiac Disease: Proceedings of the conference held Bethesda, Maryland 28-30 June 2004, edited by Elsa A. Bray and Stephen P. James, 77-78.
- Case, Shelley. "How To Provide Effective Education and Resources: Gluten-Free Diets." In NIH Consensus Development Conference on Celiac Disease: Proceedings of the conference held Bethesda, Maryland 28-30 June 2004, edited by Elsa A. Bray and Stephen P. James, 97-101.
- Ciclitira, P. "Interim Guidelines for the Management of Patients with Coeliac Disease." British Society of Gastroenterology: http://www.bsg.org.uk/bsgdisp1.php?id=c9c5177d2b91e3228066.
- Eisenbarth, George S. "Genetic Testing: Who Should Do the Testing and What Is the Role of Genetic Testing in the Setting of Celiac Disease." In NIH Consensus Development Conference on Celiac Disease: Proceedings of the conference held Bethesda, Maryland 28-30 June 2004, edited by Elsa A. Bray and Stephen P. James, 37-39.
- Fasano, Alessio et al. "Prevalence of Celiac Disdease in At-Risk and Not-At-Risk Groups in the United States: A Large Multicenter Study." Archives of Internal Medicine 163 (February 2003): 286-292.
- Gee, Samuel. "On the Coeliac Affection." Saint Bartholomew's Hospital Report 24:17-20.
- Green, Peter H.R. "The Many Faces of Celiac Disease: Clinical Presentation of Celiac Disease in the Adult Population." In NIH Consensus Development Conference on Celiac Disease: Proceedings of the conference held Bethesda, Maryland 28-30 June 2004, edited by Elsa A. Bray and Stephen P. James, 65-68.
- Holmes, Geoff. "History of coeliac disease." Coeliac UK: http://www.coeliac.co.uk/coeliac_disease/68.asp.
- Kelly, Ciaran et al. "Celiac Disease." National Digestive Diseases Information Clearinghouse (NDDIC): http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/.
- Kupper, Cynthia. "Dietary Guidelines for Celiac Disease and Implementation." In NIH Consensus Development Conference on Celiac Disease: Proceedings of the conference held Bethesda, Maryland 28-30 June 2004, edited by Elsa A. Bray and Stephen P. James, 91-95.
- Rewers, Marian J. "Epidemiology of Celiac Disease: What Are the Prevalence, Incidence, and Progression of Celiac Disease?" In NIH Consensus Development Conference on Celiac Disease: Proceedings of the conference held Bethesda, Maryland 28-30 June 2004, edited by Elsa A. Bray and Stephen P. James, 45-47.
- Rostom, Alaa. "Incidence and Prevalence of Celiac Disease." In NIH Consensus Development Conference on Celiac Disease: Proceedings of the conference held Bethesda, Maryland 28-30 June 2004, edited by Elsa A. Bray and Stephen P. James, 57-59.
- Tengah, D. S. N. A. Pegiran, A. J. Wills and G. K. T. Holmes. "Neurological complications of coeliac disease." Postgraduate Medical Journal 78 (2002): 393-398.