Celiac Disease And Autoimmune Conditions

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It is commonly recognized that celiac disease (CD, or gluten enteropathy), the inability to digest a group of grain protein popularly known as gluten, if not treated with complete avoidance, can lead to a number of conditions such as anemia, gastrointestinal upset, osteoporosis, neurological disturbances, and fatigue.  However, it is not as widely known that one can test positive for CD while having no apparent symptoms, and that untreated CD is being linked with autoimmune diseases such as type 1 diabetes, thyroid autoimmune disorder, and lymphoma. While researchers have found common genetic traits between CD and these conditions, clinical studies suggest CD, rather than being a parallel contingency, may actually ‘trigger’ the autoimmune diseases.

            When CD individuals are exposed to certain type of proteins in wheat, barley, spelt, rye, and perhaps oats (semolina, durum, couscous, and bulgur are variations of wheat), their immune system creates specific ‘antigens’ that turn against the intestinal lining, damaging it.  If the person continues to ingest gluten,  atrophy of the intestinal wall is likely to happen, but it does not always happen.  Anemia, and overall malnutrition may follow, as numerous essential nutrients, including calcium, and at least one precursor of an important pancreatic enzyme, are no longer absorbed and/or synthesized.  Different pathologies of the immune system, which are not yet fully understood, occur, leading to a wide array of conditions and symptoms.  It may be that the normal protective bacteria in the intestinal tract produce immune fighters and the body’s hard core immune system tries to adapt to fighting the by-products of this effort. Celiac disease, as one researcher notes, sets a person’s metabolism between  “a rock and a hard place.”  Moreover, one of the observed phenomenon is the ‘leaky gut,’ where the mucous membrane of the intestine is compromised and undigested food particles ‘escape’ into the bloodstream where they become toxic.  

            Allergies activate different immune compounds and is a different condition.  Practically, both situation require avoidance of the respective food item, but gluten intolerance may required a life-time avoidance, while with allergies this is not always the case.

GLUTEN, A TRIGGER FOR TYPE 1 DIABETES?

Genetic studies have detected common traits between CD  and type 1 diabetes.

It is known that type 1 diabetes is an autoimmune disorder in which the pancreatic cells called ‘beta,’ responsible for the manufacturing of insulin, are attacked by the body’s own immune cells called T helper 1 (Th1).

It was noted that the prevalence of CD among people with diabetes is higher than that in the general population.  Researchers have found common genetic traits, however  some clinical studies have shown that, when a gluten-free diet (GFD) was instituted, type 1 diabetes and other endocrine pathologies were averted or delayed in  genetically predisposed individuals.  Researchers Vijay Kumar, Manoj Rajadhyaksha, and Jacobo Wortsman from the University of Buffolo,  New York, and the School of Medicine, Southern Illinois University, set up to study the links between CD and other autoimmune pathologies.  While they did not prove the so called ‘antigen trigger hypothesis’ by which the autoimmune diseases are caused by a reaction to gluten, their review of more than 100 studies reveals that a gluten-free diet prevents other immune pathologies in those considered genetically predisposed. According to these researchers, “…the identification of such cases with CD is important since it may  help in the control of type 1 diabetes or endocrine functions in general, as well as in the prevention of long term complication of CD, such as lymphoma.” 

A dramatic study that confirms the ‘antigen trigger hypothesis’ was carried out in  a type of rats genetically predisposed to develop type 1 diabetes.   A group from the Ottawa Health Research Institute found that a majority of these type of rats actually developed diabetes when fed a wheat protein-based diet. These animals also developed a mild celiac condition  The study, reported in August, 2005, in the journal Diabetology, revealed that the destructive immune T cells multiplied in proportion with the quantity of wheat protein in the feed, while on a milk protein based diet, they remained the same as in the ‘control’ rats.  The Th1 cells, researchers concluded, “proliferate specifically in response to wheat protein antigens.”

            The implication of these results could turn promising for those with type 1 diabetes, or other autoimmune diseases who may have an overt or a ‘silent’ intolerance to gluten.

Whether or not various autoimmune diseases may be triggered by CD in predisposed individuals is an issue that researchers are still trying to address.  However, the importance of diagnosing and treating CD becomes increasingly evident from a review of the medical literature.  Kumar et. al. note that not only diabetes, but other conditions as well can be prevented.  In another example, the same authors write that, a characteristic symptom of CD, calcium malabsorption that causes bone loss with the resulting malfunctioning  of the parathyroid glands, was averted by a gluten-free diet.  The researchers note that “ A gluten-free diet in patients with CD with secondary hyperparathyroidism has been reported to result in normal bone mineral density.” 

A reassuring study of children with CD was carried out by a group of Italian researchers at the University of Palermo, Italy. The scientists set up to verify whether the insufficiency of pancreatic function in children with CD occurred independently from intestinal atrophy.  The study, with small children with CD (mean age of 4.4 years) some of whom had total atrophy of the intestinal mucosa,  revealed that, when GFD was instituted and the intestinal mucosa returned to normal, no differences in pancreatic function between CD children and controls was noted.  Testing the children after 12.9 months of gluten-free diet, the researchers concluded that  “No primary or secondary pancreatic insufficiency was found in coeliac patients where the intestinal mucosa had returned to normal.” 

            TESTING FOR CD

            In clinical setting,  CD may be diagnosed by way of an intestinal biopsy, however, those cases without gastrointestinal atrophy are often missed by such a test.  A special blood serum analysis, the endomysial antibody test, detecting certain autoimmune factors specific to gluten, emerges as the best choice, according to Kumar and colleagues, however, it appears that not all laboratories are equipped properly for this test.

One can detect a food intolerance or allergy to a certain food though ‘challenging’ or ‘provocation’ of the immune system, after avoiding the suspect food totally for a  period of time, several weeks or months for example.  When the food is reintroduced after a lengthy period, there may be an exacerbation of symptoms.  Of course, if the food ingestion is of the type known to cause life-threatening anaphylactic shock, it should not be tried at all.  Gluten intolerance is not the same as ‘allergy.’ A person may be ‘allergic’ to many foods and to any of the more than 200 different proteins in wheat (which can be similar with proteins in other grains), a situation that also requires avoidance of the offending food.  Some studies show that in the case of an allergy, a person may be able to recover after a relatively long period of abstinence relative to the allergenic food. Celiac disease on the other hand is an ‘intolerance,’ not an ‘allergy’ and some contend it is life-long and of genetic origin.  Some researchers say that children may ‘recover’ from both allergies and gluten intolerance if they avoid the foods early, however, in the light of what is now known about ‘silent’ and ‘latent’ CD, it is fair to say that there are not enough long term study with large cohorts of CD young patients to determine if this speculation has merit.  Some recent studies suggest a dual environmental/genetic components in CD.  One influential aspect noted from a study at the University of Colorado, Denver, is the age at which wheat is being introduced in an infant’s diet. Gluten is a complex protein which is difficult to digest. 

PREVALENCE OF CD

 Celiac disease is not only a misdiagnosed and underdiagnosed disease, but a common disease.  According to one researcher, it is  “…the most common lifelong disorders worldwide.” 

 A figure that is tossed around in medical abstracts is ‘one in 133’ Americans suffer with CD.   Some European researchers mention one CD case in 250 to 300 people.

            There seems to be a widespread belief that gluten intolerance is particular to areas and populations of Northern Europe, while regions that historically have used grains in their diet for a longer period of time are spared.

            A Middle Eastern group of researchers however discovered that the Middle East, India and North African countries suffer from celiac as well.  In the study published in the Best Practical Research in Clinical Gastroenterology (June 2005)  the authors revealed that the CD prevalence in these regions “is almost the same as in Western countries.”

Many people in this regions, the authors speculate may have developed milder symptoms in response to prolonged consumption. Moreover, even if clinically present, the condition is often misdiagnosed as irritable bowel syndrome or other digestive disorders.

A GLUTEN FREE DIET

            The treatment for CD consist in completely removing gluten from the diet. 

            According to German researchers Norbert Krauss and D. Schuppan, full return to normal tissue structure takes several months, and sometimes up to a year of strict gluten free diet.

Even a trace amount of gluten may trigger the harmful biochemical events leading to the compromise of the immune, endocrine and neurological systems. Gluten is ubiquitous. One patient on a gluten-free diet in a follow-up study was found to compromise his diet due to an antibiotic that contained gluten. Gluten protein makes a good paste.

The gluten free diet is a commitment which is , as British researchers N. McGough and J.H. Cummings note in a report published in November 2005 “…lifelong and many aisles in the supermarket are effectively closed to individuals with coeliac disease.” According to these clinical researchers, “ compliance can be monitored by measuring antibodies in blood, which revert to negative after 6-9 months.”

            For patients with minor symptoms, McGough and Cummings point out that
”Current advise is that dietary adherence is necessary to avoid the long-term complications, which are, principally, osteoporosis and small bowel lymphoma. However,  risk of these complications diminishes considerably in patients who are on a gluten-free diet.”

 Food manufacturers find more and more usage for gluten, and introduce it in numerous processed foods, often without using the term gluten.  A term such as ‘modified protein’ would be suspect. Often gluten is a filler that is not mentioned at all in the ingredient lists.   Processed meats and cheeses, yogurt, and all sorts of processed liquid foods, sauces, and salad dressings may contain gluten, due to certain ‘shelf’ qualities .  Labeling of processed foods with respect to gluten is on the wish list of many consumer health activists.  Meanwhile, the CD patient may need to avoid processed foods altogether, in order to be safe. Some food manufacturers are making gluten free pasta, breads, cookies, and similar items.

            The protein in oat, although from the same family, is under controversy as to the gluten free diet.  One study that compared gluten free diet with oats and a gluten free diet without oats revealed that a percentage of the CD patients fared poorly on oat meal as well. On the other hand, some of those in the gluten free without oats fared poorly as well, and that brings into question full compliance on both groups.

            About half of all food intolerant patients were found to crave the food to which they are intolerant, a feature that is not fully explained.  One speculation, based on a number of studies, is that incomplete digestion leads to the formation of certain abnormal proteins (peptides) which have an affinity for receptors in the brain  that are linked with endorphins and opioids. 

CD, AN UNDERDIAGNOSED CONDITION

A survey of physicians from the UCLA Medical Center, published  in 2005 in the  Journal of General Internal Medicine, reveals that the knowledge regarding celiac disease is quite poor.  Physicians were not aware of ‘latent’ CD, and only 13 percent of respondents knew of the link between CD and diabetes. The researchers concluded that “Lack of physician awareness of adult onset of symptoms, associated disorders, and use of serology testing may contribute to the underdiagnosis of celiac disease,”

REFERENCES

Carroccio A, Iacono G, Montalto G, Cavataio F, Di Marco C, Balsamo V, Notarbartolo A. Exocrine pancreatic function in children with coeliac disease before and after a gluten free diet. 1: Gut. 1991 Jul;32(7):796-9. Palermo, Italy.

Hollen E, Forslund T, Hogberg L, Laurin P, Stenhammar L, Falth-Magnusson K, Magnusson KE, Sundqvist T., Urinary nitric oxide during one year of gluten-free diet with or without oats in children with coeliac disease. : Scand J Gastroenterol. 2006 Nov;41(11):1272-8.  Sweden.

Nousia-Arvanitakis S. Fotoulaki M. Tendzidou K, Vassilaki C, Agguridaki C, Karamouzis M. Sublicnical exocrine pancreatic dysfunction resulting from decreased cholecystokinin secretion in the presence of intestinal villous atropy. J. Pediatr. Gastroenterol Nutr. 2006 Sep;43(3):307-12. Thessaloniki, Greece.

Arato A, Korner A, Veres G, Dezsofi A, Ujpal I, Madacsy L., Frequency of coeliac disease in Hungarian children with type 1 diabetes mellitus. Eur J. Pediatr. 2003 Jan; 162(1):1-5. Budapest, Hungary.

Amin R, Murphy N, Edge J, Ahmed ML, Acerini CL, Dunger DB, A longitudinal study of the effects of a gluten-free diet on glycemic control and weight gain in subjects with type 1 diabetes and celiac disease. Diabetes Care. 2002 Jul;25(7):1117-22.  Cambridge, UK.

McGough N, Cummings, JH.  Coeliac disease: a diverse clinical syndrome caused by intolerance to wheat, barley and rye. Proc. Nutr. Soc. 2005 Nov. 64(4):434-50

Krauss N., Schuppan D, Monitoring nonresponsive patients who have celiac disease. Gastrointest. Endosc. Clin. N Am. 2006 Apr. 16(2):317-27 

Zipser RD, Farid M, Baisch D, Patel B, Patel Dt .

Physician awareness of celiac disease: a need for further education.

1: J Gen Intern Med. 2005 Jul;20(7):644-6.  

Leone JE, Gray KA, Massie JE, Rossi JM. Celiac disease symptoms in a female collegiate tennis player: a case report. J Athl Train. 2005 Oct-Dec;40(4):365-9. Carbondale, Il.

Copyright  Elena Marcus  2007

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Disclaimer:  This information is not intended to treat or prevent diseases, but is given here for merely educational purposes.