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The current “gold standard” tests for celiac disease include testing for celiac antibodies in patients’ blood and performing an endoscopy to obtain small bowel biopsies. In order for these tests to be accurate, one has to be eating gluten up until the time of testing. If a patient is already on the gluten-free diet when these tests are done, the diagnosis of celiac disease can easily be missed.
I’ve encountered many people who have decided that they’d like to be tested for celiac disease after starting on the gluten-free diet. Per the celiac disease experts, a “gluten challenge” must be performed in these cases to assist in the diagnosis of celiac disease. A gluten challenge requires eating foods containing gluten for a prescribed period of time prior to an endoscopy and/or blood testing for celiac disease. The length of time and amount of gluten that need to be consumed for a gluten challenge vary from source to source. Here are some examples of different recommendations for a gluten challenge (current as of July 5, 2014):
[url="http://www.cureceliacdisease.org/archives/faq/what-is-a-gluten-challenge"]University of Chicago Celiac Disease Center:[/url] “For a gluten challenge we recommend eating 1/2 slice of bread or a cracker each day for the duration of the challenge. Prior to blood testing we recommend 12 weeks of eating gluten. Prior to an endoscopic biopsy we recommend 2 weeks of eating gluten. In the case of a severe reaction to gluten, a medical professional may opt to shorten the 12-week challenge and move immediately to an endoscopic biopsy.”
[url="http://sklad.cumc.columbia.edu/celiacdiseasecenter/celiac-disease/diagnosis/difficult-situations/"]Celiac Disease Center at Columbia University[/url]: “In individuals who are willing to further pursue the question of whether they have celiac disease, we will advise a gluten challenge. This consists of ingesting at least 4 slices of bread a day for one to three months followed by an endoscopy and biopsy. There is no evidence that following antibody tests is beneficial in establishing a diagnosis of celiac disease because these tests are not sensitive in this setting.”
[url="http://bidmc.org/Centers-and-Departments/Departments/Digestive-Disease-Center/Celiac-Center/FAQ/DiagnosingCeliacDisease.aspx#challenge"]Celiac Disease Center at Beth Israel Deaconess Medical Center:[/url] “Gluten is reintroduced into the diet and after a period of time (ideally 6 to 8 weeks if the challenge can be tolerated for that long) blood tests and an intestinal biopsy are performed. If the gluten challenge is not tolerable for the full 8-week period blood tests and biopsy can be performed sooner but this can lead to a false negative result.”
In addition, Dr. Leffler and colleagues published a [url="http://www.ncbi.nlm.nih.gov/pubmed/22619366"]paper[/url] in 2013 showing that the majority of patients with celiac disease will test positive after eating >3g gluten/day for 2 weeks. A typical piece of wheat bread contains about 5g of gluten.
Despite all of the confusion, there is hope on the horizon for a shorter gluten challenge in the future. Researchers at the [url="http://www.wehi.edu.au/"]Walter and Eliza Hall Institute[/url] in Australia have been developing a blood test that measures gluten-reactive T cells, immune cells that increase in response to gluten in those with celiac disease, via cytokine release assays. In a pilot study published earlier this year, patients with celiac disease had a significant jump in blood levels of gluten-responsive T cells, compared to controls, after only 3 days of consuming gluten. Per Dr. Jason Tye-Din, one of the researchers working on this test, “We hope that larger studies can validate these findings and establish its role in the diagnosis of celiac disease.” For the sake of my gluten-light kids, and everyone else who is in a similar situation in regards to diagnosis, I hope he is right.
A press release regarding the study can be found [url="http://www.sciencedaily.com/releases/2014/01/140113154219.htm"]here.[/url]
Out of curiosity, have any of you been diagnosed with celiac after doing a gluten challenge? If so, do you remember how much gluten you had to eat and for how long prior to testing?
[color=rgb(0,0,0)][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Ontiveros%20N%5BAuthor%5D&cauthor=true&cauthor_uid=24192268"][color=rgb(0,0,0)]Ontiveros N[/color][/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Tye-Din%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=24192268"][color=rgb(0,0,0)]Tye-Din JA[/color][/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Hardy%20MY%5BAuthor%5D&cauthor=true&cauthor_uid=24192268"][color=rgb(0,0,0)]Hardy MY[/color][/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Anderson%20RP%5BAuthor%5D&cauthor=true&cauthor_uid=24192268"][color=rgb(0,0,0)]Anderson RP[/color][/url]. Ex-vivo whole blood secretion of interferon (IFN)-γ and IFN-γ-inducible protein-10 measured by enzyme-linked immunosorbent assay are as sensitive as IFN-γ enzyme-linked immunospot for the detection of gluten-reactive T cells in human leucocyte antigen (HLA)-DQ2·5(+) -associated coeliac disease. [url="http://www.ncbi.nlm.nih.gov/pubmed/?term=ex+vivo+whole+blood+secretion+celiac+disease"][color=rgb(0,0,0)]Clin Exp Immunol.[/color][/url] 2014 Feb;175(2):305-15.[/color][/font][/color]
I first came across the term “celiac disease autoimmunity” a few weeks ago as I read summaries of the article “Risk of Pediatric Celiac Disease According to HLA Haplotype and Country” that was published in the July 3[size=2], [/size]2014 issue of the [i]New England Journal of Medicine[/i](NEJM).[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Based on my reading and interpretation of the article, it seems that celiac disease autoimmunity is interchangeable with the more commonly used term “potential celiac disease.” Both are used to describe cases in which people have abnormally high levels of celiac antibodies (TTG IgA) in their blood but their small intestinal biopsies do not show changes consistent with celiac disease. In other words, there is an autoimmune response to gluten that has yet to cause destruction to the villi of the small intestine. For the sake of this study, the subjects had to have abnormally high TTG IgA levels on 2 separate occasions, at least 3 months apart, to be labeled as having celiac disease autoimmunity.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
The results published in NEJM come from the multinational TEDDY study, which is prospectively following a large cohort of children who are at genetically at risk of developing Type 1 (juvenile) diabetes mellitus. Since some children with both Type 1 diabetes and celiac disease share the same “at-risk” genes, HLA-DQ2 and DQ8, the researchers have also been able to follow a large group of genetically-susceptible children for the development of celiac disease. The study is ongoing and subjects are being followed for the development of both diabetes and celiac disease from infancy until age 15. This is one of many papers that have already come from the TEDDY study.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Thus far, 6403 study subjects have been found to have genes that predispose to celiac disease. Subjects have been placed into 4 risk groups:[/font][/color][color=rgb(68,68,68)][font='Open Sans']
-HLA DQ2/HLA DQ2 (homozygous for DQ2)[/font][/color][color=rgb(68,68,68)][font='Open Sans']
-HLA DQ2/HLA DQ8[/font][/color][color=rgb(68,68,68)][font='Open Sans']
-HLA DQ8/HLA DQ8 (homozygous for DQ8)[/font][/color][color=rgb(68,68,68)][font='Open Sans']
-HLA DQ8/HLA DQ4[/font][/color][color=rgb(68,68,68)][font='Open Sans']
As you can see, the first 3 groups of kids all have 2 copies of celiac-risk genes, and the 4[size=2]th[/size]group has only one copy of DQ8, so only one gene associated with celiac disease. Subjects’ testing for celiac disease autoimmunity started at age 24 months and has been repeated every year. In all, 786 of the 6403 (11%) at risk subjects were found to have celiac disease autoimmunity (elevated blood TTG IgA antibodies at least twice) at time of data analysis Overall, 25% of the children with celiac disease autoimmunity had a diagnosis of celiac disease by age 3.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
The researchers broke down the risk of both celiac disease autoimmunity and celiac disease by genes and found the following risks by age 5:[/font][/color][color=rgb(68,68,68)][font='Open Sans']
[color=rgb(51,102,255)][b]Celiac Disease Autoimmunity Risk in Children with Celiac Genes by Age 5[/b][/color]:[/font][/color][color=rgb(68,68,68)][font='Open Sans']
HLA DQ2/HLA DQ2 (homozygous for DQ2): 26%[/font][/color][color=rgb(68,68,68)][font='Open Sans']
HLA DQ2/HLA DQ8: 11%[/font][/color][color=rgb(68,68,68)][font='Open Sans']
HLA DQ8/HLA DQ8 (homozygous for DQ8): 8%[/font][/color][color=rgb(68,68,68)][font='Open Sans']
HLA DQ8/HLA DQ4: 3%[/font][/color][color=rgb(68,68,68)][font='Open Sans']
[color=rgb(51,102,255)][b]Celiac Disease Risk in Children with Celiac Genes by Age 5[/b]:[/color][/font][/color][color=rgb(68,68,68)][font='Open Sans']
HLA DQ2/HLA DQ2 (homozygous for DQ2): 11%[/font][/color][color=rgb(68,68,68)][font='Open Sans']
HLA DQ2/HLA DQ8: 3%[/font][/color][color=rgb(68,68,68)][font='Open Sans']
HLA DQ8/HLA DQ8 (homozygous for DQ8): 3%[/font][/color][color=rgb(68,68,68)][font='Open Sans']
HLA DQ8/HLA DQ4: less than 1%[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Children with both celiac disease and celiac disease autoimmunity were found to be at a higher risk of having diabetes than the general population (1% for celiac disease autoimmunity and 2% for celiac disease v. 0.3% risk for general U.S. population).[/font][/color][color=rgb(68,68,68)][font='Open Sans']
In summary, in this large study, [b]over 25% of children with the DQ2/DQ2 genotype were found to have celiac disease autoimmunity by age 5 and greater than 10% with DQ2/DQ2 were diagnosed with celiac disease by age 5.[/b] Over half of these children had no symptoms of celiac disease, therefore, there is a good chance that many of these diagnoses would have been missed if these children had not been subjects in this study.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
After reading this article I am a much stronger proponent of genetic testing of children at risk for celiac disease, if possible. And, as my husband and I both carry genes associated with celiac disease, I feel much less guilty for making my own kids get screened for celiac disease, via TTG IgA blood testing, every 2 years. Lastly, I feel much more at peace for making my at-risk youngest go through having an endoscopy and small bowel biopsy earlier this summer. The statistics from this study are definitely eye-opening.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
[b]Reference:[/b] Liu E, Lee HS, Aronsson CA, et al. TEDDY Study Group. [url="http://www.ncbi.nlm.nih.gov/pubmed/24988556"]Risk of pediatric celiac disease according to HLA haplotype and country.[/url] [i]N Engl J Med[/i][i].[/i] 2014 Jul 3;371(1):42-9.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Also, if you are a research geek like I am, here are some other interesting findings from the TEDDY study thus far (found via a Pubmed.gov search):[/font][/color][list]
[*]The HLA-DQ2/2 genotype may predispose to obesity among 2-4-year-old children.
[*]Between 15% and 20% of the infants in the study were introduced to solid foods before the age of 4 months.
[*]The median age of early-onset diabetes is at 2.3 years. 33% of the subjects with an early diagnosis of diabetes had no symptoms of diabetes.
[*]Findings have not supported the presence of viremia (recent viral infection) around the time of seroconversion in young children with rapid-onset type 1 diabetes.
[color=rgb(68,68,68)][font='Open Sans']There is a well-established relationship between celiac disease (and non-celiac gluten sensitivity) and the development of neurologic problems in adults. According to Dr. Marios Hadjivassiliou, a neurologist in the UK who is one of the world’s experts in this area, up to 50% of adults with newly diagnosed celiac disease have signs or symptoms of neurological problems. I have personally experienced a peripheral neuropathy (nerve damage) as a result of celiac disease and it was my neuropathy that prompted me to start writing about my experiences in 2012. If you are interested in learning more about gluten-related neurologic problems in adults, I urge you to read Christine Boyd’s article “Gluten and Your Brain” in the April/May 2014 issue of [i]Living Without[/i] Magazine. The article contains a wealth of information from experts, including Drs. Fasano and Hadjivassiliou.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']Although there is definitely a link between gluten-related disorders and nerve and brain problems in adults, much less in known about the neurologic signs and symptoms in children with gluten sensitivity. This may be in part due to a 2008 paper in the [i]Journal of Pediatrics[/i] that concluded that neurologic problems in children with celiac disease are rare. I have personally interacted with many parents of children with both celiac disease and non-celiac gluten sensitivity who have had their children’s neurologic and behavioral symptoms improve on the gluten-free diet. In addition, in just the last few weeks, there have been several published case reports regarding gluten-induced neurologic problems in kids. If you are interested in learning about the case reports, I have summarized them below:[/font][/color][list=1]
[*]The 1[size=2]st[/size] case report is of a 15 year old girl with celiac disease who developed a peripheral neuropathy out of the blue that consisted of weakness and a pricking sensation in her legs. It was discovered that she had been accidentally eating biscuits that contained gluten for about 2 months prior to the neuropathy starting. Her neuropathic symptoms resolved when she stopped eating the non-gluten-free biscuits (see reference #3).
[*]The 2[size=2]nd[/size] case report is of a 3 year old girl who developed an acute disseminated encephalomyelitis (brain inflammation) and white matter lesions that were visible on her brain MRI. After going on the gluten-free diet her neurological symptoms resolved and the white matter lesions stopped growing in size (see reference #4).
[*]The 3[size=2]rd[/size] case report is of a 2 year old boy with epilepsy who continued to have seizures despite being on multiple seizure medications. He did not have any digestive symptoms, outside of canker sores in his mouth, but was found to carry one of the 2 main celiac genes (HLA-DQ8). Within 6 months of being on the gluten-free diet, his seizures improved, his EEG became normal, and he was able to be weaned off of all his seizure medications (see reference #5).
[color=rgb(68,68,68)][font='Open Sans']According to Dr. Guandlini, the founder and medical director of [url="http://www.cureceliacdisease.org/"]The University of Chicago Celiac Disease Center,[/url] who wrote a recent review [url="http://www.ncbi.nlm.nih.gov/pubmed/24395055"]article[/url] about celiac disease in children, neurologic signs and symptoms of celiac disease in the pediatric population can include all of the following: cerebellar ataxia, recurring headaches, peripheral neuropathy, seizures, and psychiatric disorders, including anxiety, panic attacks, and depression.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']In writing and sharing this post I am not trying to state that all neurologic problems in kids are as a result of gluten, as this is clearly not the case. I am sharing this information in hopes that both celiac disease and non-celiac gluten sensitivity may be on both parents’ and doctors’ radars when neurologic signs and symptoms appear in kids, as well as to help prevent others from having a long delay in diagnosis like I did.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']Thank you for reading and please feel free to share your personal experiences in the comments section.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']Hadjivassiliou, M, Sanders, D, Grubewald, R, et al. Gluten sensitivity: from gut to brain. [i]The Lancet.[/i] March 2010. 9: 318-330.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans'][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Ruggieri%20M%5BAuthor%5D&cauthor=true&cauthor_uid=18206697"]Ruggieri M[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Incorpora%20G%5BAuthor%5D&cauthor=true&cauthor_uid=18206697"]Incorpora G[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Polizzi%20A%5BAuthor%5D&cauthor=true&cauthor_uid=18206697"]Polizzi A[/url], et al. Low prevalence of neurologic and psychiatric manifestations in children with gluten sensitivity. [i][url="http://www.ncbi.nlm.nih.gov/pubmed/18206697"]J Pediatr.[/url][/i] 2008 Feb; 152(2):244-9.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans'][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Boskovic%20A%5BAuthor%5D&cauthor=true&cauthor_uid=24825274"]Boskovic A[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Stankovic%20I%5BAuthor%5D&cauthor=true&cauthor_uid=24825274"]Stankovic I[/url]. Axonal and demyelinating polyneuropathy associated with celiac disease. [url="http://www.ncbi.nlm.nih.gov/pubmed/24825274"][i]Indian Pediatr[/i].[/url] 2014 Apr 8; 51(4):311-2.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans'][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Jorge%20R%5BAuthor%5D&cauthor=true&cauthor_uid=24819886"]Jorge R[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Aguiar%20C%5BAuthor%5D&cauthor=true&cauthor_uid=24819886"]Aguiar C[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Espinheira%20C%5BAuthor%5D&cauthor=true&cauthor_uid=24819886"]Espinheira C[/url], et al. A pediatric case of gluten sensitivity with severe neurological presentation. [url="http://www.ncbi.nlm.nih.gov/pubmed/?term=pediatric+gluten+sensitivity+severe+neurological"][i]Eur J Pediatr[/i].[/url] 2014 May 13. [Epub ahead of print][/font][/color]
[color=rgb(68,68,68)][font='Open Sans'][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Bruni%20O%5BAuthor%5D&cauthor=true&cauthor_uid=24813861"]Bruni O[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Dosi%20C%5BAuthor%5D&cauthor=true&cauthor_uid=24813861"]Dosi C[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Luchetti%20A%5BAuthor%5D&cauthor=true&cauthor_uid=24813861"]Luchetti A[/url], et al. An unusual case of drug-resistant epilepsy in a child with non-celiac gluten sensitivity. [url="http://www.ncbi.nlm.nih.gov/pubmed/24813861"][i]Seizure[/i].[/url] 2014 Apr 18. pii: S1059-1311(14)00106-X. doi: 10.1016/j.seizure.2014.04.005. [Epub ahead of print][/font][/color]
I think most of us have met people who have symptoms of celiac disease, but when tested, are told that their celiac antibody blood tests and biopsy results are negative (normal). Some of these people are labeled “gluten intolerant” or “gluten sensitive” by their doctors, others are told they may have “early” celiac disease, or “pre” celiac disease, and the rest are told that they have nothing wrong and are often advised to continue to eat gluten. Many continue to eat gluten and find themselves getting sicker and sicker, with an improvement or disappearance of symptoms when they go gluten-free. Then, when they go gluten-free, since they are “gluten intolerant” as opposed to having celiac disease, it is unclear how closely they need to be followed for vitamin deficiencies, the development of additional autoimmune disorders, and other problems that are associated with long-standing celiac disease.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Whenever I hear that a person is “gluten intolerant” I wonder whether or not the diagnosis of celiac disease was actually missed. Celiac blood antibody testing can be unreliable in infants and toddlers, people who have a condition called serum IgA deficiency (occurs in up to 3% of celiacs), and when patients are tested after they have already started on the gluten-free diet. Likewise, endoscopies and biopsies are often done incorrectly which can lead to celiac-induced intestinal damage being missed.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
I recently read, with much interest, an article called, “Intestinal-mucosa anti-transglutaminase antibody assays to test for genetic gluten intolerance,” which was published this month by a group of celiac researchers in Italy. Although it’s a bit technical, I will do my best to summarize it for you.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
In this study, the gluten-intolerant subjects consisted of 78 pediatric patients who had symptoms of celiac disease but normal celiac antibodies (anti-TTG, also called TTG IgA) and normal small bowel biopsies. None of the subjects were IgA deficient. Of the 78 gluten intolerant subjects, 12 were found to have anti-TTG antibodies present in the tissue biopsies from their intestines–to clarify, anti-TTG antibodies were found in their intestines, but not in their blood. 3 of the 12 patients in this “gluten intolerant” group, with TTG antibodies localized to the intestine only, were started on a GFD diet and they all had improvement in symptoms and anemia after 24 months on the gluten-free diet. Of the 9 patients with anti-TTG antibodies in the intestines who were continued on a gluten-containing diet, 2 of the 12 had celiac disease at 24 month follow-up. The remaining 7 “gluten intolerant” subjects who remained on gluten-containing diets appeared to have an improvement in symptoms at the 24 month mark, but it is unclear if this reflected a period of remission v. a true resolution of the intestinal antibody response, as there has been no long term follow-up, and as far as I can tell, biopsies were not repeated.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Although this study has a very small sample size, it demonstrates that there are some “gluten intolerant” patients who actually have subclinical celiac disease. In these cases, the celiac immune response is contained to the intestines only and villous atrophy (the hallmark of celiac disease) has not yet occurred. It appears that these individuals benefit from treatment with the gluten free diet.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
I am curious to see if the long-term follow-up of the remaining 7 gluten intolerant subjects will be published in the future, and if some of them will also go on the develop celiac disease. I am also curious to see if celiac antibody testing of intestinal biopsy specimens will eventually become part of the standard of care in the clinical investigation of celiac disease.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Quaglia, S, De Leo, L, Ziberna, F, et al. [url="http://www.ncbi.nlm.nih.gov/pubmed/24769794"]Intestinal-mucosa anti-transglutaminase antibody assays to test for genetic gluten intolerance[/url]. Cellular and Molecular Immunology advance online publication, 28 April 2014; doi:10.1038/cmi.2014.32.[/font][/color]
[font=georgia][color=rgb(68,68,68)]Unexplained joint pains (arthralgias) were one of the main symptoms that I dealt with prior to my celiac diagnosis. Throughout my twenties I had pain and stiffness in my fingers, knees and ankles that would come and go with no apparent explanation. I ran track for part of high school and continued to run for fitness during college, but shortly after graduating had to stop running for a long time due to my joint issues. I was evaluated over and over again for lupus, rheumatoid arthritis, Lyme Disease, etc. but there were never any answers for why I had developed the pains. So I learned to live with them and I stopped running. Fortunately, since going gluten-free in 2010 my arthralgias have almost entirely disappeared, and I was able to resume running again.[/color]
[color=rgb(68,68,68)]Based on previous research, up to 25% of people with celiac disease may experience joint pains. In just the last few months there have been a few interesting studies published about the relationship between celiac disease and joint issues.[/color][/font]
[font=georgia][color=rgb(68,68,68)]A group of researchers published a paper last week showing a significant relationship between joint inflammation and celiac disease in children. They evaluated the knees, hips, and ankles of children with celiac disease (n=74) by ultrasound. They compared ultrasound findings of those with treated v. untreated celiac disease and found that [b]50%[/b] of those who were not on the gluten-free diet had evidence of joint inflammation v. only 11% of those who were gluten-free.[/color][/font]
[font=georgia][color=rgb(68,68,68)]In a recent Tunisian study, researchers tested over 200 women with unexplained arthralgias (joint pains) for celiac disease. They found much high rates of undiagnosed celiac disease in their sample (2.37%) than in the general population in their country (0.28%). Interestingly enough, all of the women who were diagnosed did have other symptoms of celiac disease, such as anemia and infertility, when their medical records were reviewed after-the-fact.[/color][/font]
[font=georgia][color=rgb(68,68,68)]In addition, Dr. Guandalini refers to the relationship between celiac disease and arthritis in his review of celiac disease in children that was published earlier this month in JAMA Pediatrics (see my previous post for a summary and for the actual reference).[/color][/font]
[font=georgia][color=rgb(68,68,68)]Although the relationship (or lack of one) between juvenile idiopathic arthritis (JIA) and celiac disease appears to be debatable in the medical literature, this [url="http://www.nytimes.com/2013/02/03/magazine/the-boy-with-a-thorn-in-his-joints.html"]story[/url], which was published last year in the NY Times, does present a compelling case for a link, at least in some cases.[/color][/font]
[font=georgia][color=rgb(68,68,68)]Have any of you experienced celiac-related joint pains? If so, please share, as your stories may lead others to be diagnosed…[/color][/font]
[*][font=georgia]Lubrano E, Ciacci C, Ames PR, et al. The arthritis of coeliac disease: prevalence and pattern in 200 adult patients. Br J Rheumatol. 1996;35(12):1314.[/font]
[*][font=georgia][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Iagnocco%20A%5BAuthor%5D&cauthor=true&cauthor_uid=24447910"]Iagnocco A[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Ceccarelli%20F%5BAuthor%5D&cauthor=true&cauthor_uid=24447910"]Ceccarelli F[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Mennini%20M%5BAuthor%5D&cauthor=true&cauthor_uid=24447910"]Mennini M[/url], et al. Subclinical synovitis detected by ultrasound in children affected by coeliac disease: a frequent manifestation improved by a gluten-free diet.[url="http://www.ncbi.nlm.nih.gov/pubmed/24447910"]Clin Exp Rheumatol.[/url] 2014 Jan 20. [Epub ahead of print][/font]
[*][font=georgia][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Ghozzi%20M%5BAuthor%5D&cauthor=true&cauthor_uid=24292850"]Ghozzi M[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Sakly%20W%5BAuthor%5D&cauthor=true&cauthor_uid=24292850"]Sakly W[/url], [url="http://www.ncbi.nlm.nih.gov/pubmed?term=Manka%C3%AF%20A%5BAuthor%5D&cauthor=true&cauthor_uid=24292850"]Mankaï A[/url], et al. Screening for celiac disease, by endomysial antibodies, in patients with unexplained articular manifestations. [url="http://www.ncbi.nlm.nih.gov/pubmed/24292850"]Rheumatol Int.[/url] 2013 Dec 1. [Epub ahead of print][/font]
Drs. Guandalini and Assiri have written a summary of pediatric celiac disease that was published in the online edition of the journal JAMA Pediatrics last week. In this post I will share some of the highlights of their review article.
Although the overall prevalence of celiac disease is 1% in the pediatric population, only 10-15% of children with celiac disease have been diagnosed and treated.
The celiac genes (HLA-DQ2 and DQ8) contribute 40% of the risk of developing celiac. Environmental risk factors for celiac disease include infant feeding patterns, early infections, gut microbiota, and the amount and timing of initial gluten exposure.
The two major autoantibodies used in the diagnosis of celiac disease include the anti-TTG IgA and antiendomysial IgA. The antibody against deamidated gliadin peptides IgG (DGP IgG) is a 3rd antibody that has been identified. The DGP IgG may be the best one to use for diagnosing celiac disease in young children (under the age of 2) as it has the highest sensitivity in this age group.
During the past few decades there has been a shift from children presenting with celiac disease having typical symptoms (gastrointestinal) to having extraintestinal (atypical) symptoms.
“Typical” symptoms include abdominal pain (most common), diarrhea, chronic constipation, weight loss, vomiting, abdominal distension, and malnutrition.
“Atypical” (extraintestinal) symptoms in children include all of the following:
iron deficiency anemia
dental enamel defects
aphthous ulcers (canker sores)
arthritis and arthralgias (joint pains)
low bone mineral density, fractures of bones
elevated liver enzymes
psychiatric disorders, including anxiety, panic attacks, depression
Celiac disease is associated with other pediatric conditions, including type 1 diabetes mellitus, selective IgA deficiency, Down syndrome, Turner syndrome, and Williams syndrome.
Patients with celiac disease are at an increased risk of all of the following (I was not aware of many of these associations until I read this article):
ischemic heart disease
Dr. Guandalini recommends that celiac diagnosis in children involve celiac antibody testing, endoscopy with small bowel biopsy, and response to the gluten free diet. He does discuss that the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) has recently issued guidelines for diagnosis in which, in select cases, the small bowel biopsy can be omitted. Dr. Guandalini’s major concern is that if children undergoing evaluation do not have biopsies done, that other GI diagnoses that may need treatment, such as eosinophilic esophagitis, can be missed.
Celiac Disease resources that were discussed toward the end of the article include the Academy of Nutrition and Dietetics website, www.eatright.org, and an e-book created by the University of Chicago Celiac Disease Center called “Jump Start Your Gluten-Free Diet.”
In summary, this is a nicely written paper that is a great summary for pediatricians and other practitioners who need to be on the look out for celiac disease in their pediatric patients. I also thought that some of you non-medical folks might be interested as well!
Reference: Guandalini S, Assiri A. Celiac Disease: A Review. JAMA Pediatr. 2014 Jan 6. doi: 10.1001/jamapediatrics.2013.3858.
Thank you for reading!
At this time last year I had never heard of mast cell activation syndrome (MCAS) and the first time that I heard the name I thought that it was a “made up” disease. Since then I have come to realize that it is a real diagnosis and I have learned a ton about it, including the following:
MCAS is a newly recognized disease of the innate immune system (our bodies’ first line of defense against bacteria, viruses, parasites, and other invaders).
Women make up the majority of patients with MCAS.
Symptoms are caused by having too much histamine in one's system and can affect almost any part of the body (see comprehensive list below).
MCAS is very common (there is pilot data showing that 17% of Germans are affected to some degree).
It is acquired during life; no one is born with MCAS and it is not yet known why it develops in certain people.
I am one of the unlucky people to have acquired MCAS during my journey through life. Although I really wish that I didn’t have it, I am sharing my story in hopes that I can help others.
Mast cells are innate immune cells that play a role in defending the body against bacteria, viruses, and parasites, but are best known for their participation in the allergic response. When mast cells degranulate, or burst open, histamine and other chemicals are released, leading to symptoms which we associate with allergies, including having a runny nose, wheezing, hives, etc. Most of us are familiar with the antihistamine drugs that are used to treat allergic symptoms, such as Claritin, Allergra, and Zrytec. Although these medications do not prevent mast cells from releasing histamine, they prevent symptoms by blocking histamine receptors.
In mast cell activation syndrome (also known as mast cell activation disorder, or MCAD), mast cells have excessive degranulation, release too much histamine, and adverse symptoms develop. Symptoms can vary from person to person and will often become worse in the same person with time. Some patients will experience only one or two symptoms from having too much histamine floating around, and other patients will experience many, many symptoms. Although urticaria (hives) is the classic symptom associated with mast cell degranulation, in many cases patients with MCAS do not have urticaria or any skin findings. I have never had hives and the only skin symptom that I get from MCAS is facial flushing from time to time.
According to the Mastocytosis Society Canada’s website, the most common symptoms of MCAS include the following:
Gastrointestinal symptoms, including nausea, vomiting, diarrhea, abdominal pain, bloating, and malabsorption* (sounds a lot like celiac and/or irritable bowel syndrome doesn’t it?)
Low blood pressure*
Itching, flushing*, hives
Episodes of fainting or dizziness
Cognitive impairment (brain fog)*
Rapid weight gain or loss
Chest pain and/or a racing heart*
Sensitivity to sunlight
* = symptoms that I have personally experienced as a result of MCAS. I saw several different subspecialists before we were able to piece all of these symptoms together.
Common triggers for mast cell degranulation in those of us with MCAS include the following:
pain medications such as NSAIDs and narcotics
foods and drinks that are high in histamine or are known to trigger histamine release
extreme temperatures, both hot and cold
strong scents including perfumes and chemicals
friction, pressure, or vibration on the skin
emotional and physical stress
At this point, my only known triggers for MCAS are high histamine foods and foods that are histamine-releasing, including fermented foods and foods/drinks that have added sulfites. Please see my previous post “Celiac Disease and Multiple Food Intolerances” from July 2013 for more details on food triggers and high histamine foods. Since beginning treatment for MCAS late last summer, the other food intolerances that I had attributed to my celiac disease have markedly improved. My sulfite allergy/intolerance also appears to have been as result of untreated MCAS.
The first case reports of MCAS were just published in the medical journals in 2007 or 2008, so in most cases, the only doctors who have learned about MCAS during medical school are the really young ones. Systemic mastocytosis (SM) is a well-known, very serious mast cell disease in which there are too many mast cells in the body that invade into other parts of the body, including the bone marrow. In MCAS patients the numbers of mast cells are normal (this is what differentiates it from SM) but the mast cells that are present are overly active and degranulate much more often than they should. SM and MCAS share a lot of the same symptoms but MCAS is on a milder scale.
According to Dr. Larry Afrin, MD, a professor at the University of South Carolina who is one of the world’s experts on MCAS, testing should consist of the following:
1. Complete blood cell count with manual differential, comprehensive metabolic panel, and a serum magnesium level (these are usually part of a doctor’s evaluation for a patient presenting with any type of chronic illness). Coagulation studies and serum immunoglobulin levels may need to be done depending on presenting symptoms.
2. Blood tests consisting of serum tryptase and plasma histamine levels. If the tryptase is greater than 20 ng/mL, then a patient must be evaluated for systemic mastocytosis. In MCAS the tryptase, although often elevated, is almost always less than 20 mg/dL.
3. Plasma prostaglandin D2 (PGD2) and heparin levels.
4. Chilled 24 hour urine sample for PGD2 and methylhistamine.
In many cases of MCAS the baseline tryptase and histamine levels can be normal, so it is important for a patient to have these labs done two times (both at baseline and when symptomatic). Both blood and urine levels of histamine and tryptase should rise after mast cells are triggered. Therefore, MCAS cannot be ruled out based on one set of normal labs. This differs from many other diseases that can be ruled out if an initial set of lab tests are normal. In my case I had abnormally high urine prostaglandin levels on two separate occasions and my tryptase and histamine levels rose when I was symptomatic (both were totally normal at baseline when I did not have any symptoms going on).
Treatment options for MCAS include H1 antihistamines (such as Claritin, Allegra, and Zrytec and their generic forms), H2 antihistamines (such as Pepcid and Zantac), and mast cell stabilizers such as ketotifen and cromolyn sodium. I initially had a difficult time finding an H1-blocking antihistamine that worked for me, as most contain cornstarch and other sulfited ingredients which are triggers for my mast cells to degranulate. But I have recently done very well taking a compounded sulfite-free form of generic Claritin twice a day. I have also done my best to follow a low-histamine diet, and I believe that this has made the biggest difference in my symptoms improving. Yasmina, the Low Histamine Chef, who also has MCAS, has been a wonderful resource for learning about the low-histamine diet and recipes. If I keep my overall histamine intake low, I find that I can indulge in an occasional glass of wine or enjoy a small serving of aged cheese without starting to wheeze like I used to in the past.
Interestingly enough, since starting on this MCAS journey I have met about a dozen or so other women who have both celiac disease and MCAS. Many of us have found that our MCAS/histamine symptoms seem to spiral out of control after getting accidentally "glutened." DAO, the enzyme in our bodies that breaks down histamine, is produced in our digestive systems, so it does make sense that the gut damage we experience from gluten may lead to a decrease in DAO (and hence, our bodies getting overwhelmed with histamine that cannot be broken down). My gut instinct (no pun intended) is that many of us with celiac disease and non celiac gluten sensitivity have MCAS going on to some degree. I guess that time will tell...In the meantime, if you are experiencing symptoms that seem puzzling, involve multiple systems of your body, and popped up out of the blue, I encourage you to look into MCAS as a possibility and discuss your symptoms with your doctor.
There are some great references on the internet for learning about mast cell activation syndrome and histamine intolerance, including the following:
1. Mastocytosis and Mast Cell Disorders from the Mastocytosis Society Canada's website (www.mastocytosis.ca). Accessed Jan. 3, 2014.
2. Presentation, Diagnosis, and Management of Mast Cell Activation Syndrome by Lawrence Afrin, MD, chapter 6 in the book Mast Cells edited by David B. Murray, 2013.
3. Histamine Intolerance on Allergy UK website (www.allergyuk.org). Accessed Jan. 3, 2014.
4. Mast cell activation syndrome: a newly recognized disorder with systemic clinical manifestations. Hamilton, M., Hornick, J., Akin, C., et al. J Allergy Clin Immunol. 2011. 128 (1): 147-152.
5. Mast Cell Activation Syndrome: A Review. Frieri, M., Patel, R., Celestin, J. Curr Allergy Asthma Rep. 2013. 13: 27-32.
6. Histamine Intolerance by Dr. Janice Joneja on webpage www.foodsmatter.com. Accessed Jan. 3, 2014.
7. Expanding spectrum of mast cell activation disorders: monoclonal and idiopathic mast cell activation syndromes. Picard, M., Giavina-Bianchi, P., Mezzano, V., et al. Clinical Therapeutics. 2013. 35(5): 548-562.
Dr. Afrin's chapter on MCAS for physicians (#2 above) is the most comprehensive document that I have come across regarding all that is known about MCAS.
Lastly, I would like to thank my friend Harriet for all of her advice and help on this journey. If it was not for her assistance, I would probably still be wheezing and flushing with chronic brain fog and irritable bowel syndrome despite being strictly gluten free.
Happy New Year and thank you for reading!
I was thrilled to come across a paper about non-celiac gluten sensitivity in children in the Journal of Pediatrics, one of the main pediatric journals. Many of my pediatrician colleagues read this journal on a regular basis. In this article, a group of Italian researchers has described the symptoms and lab test results in 15 children with gluten sensitivity (GS) compared to 15 children with active celiac disease and 15 controls (children with IBS-type symptoms that have no correlation with gluten intake). None of the children included in the GS group had an IgE-mediated wheat allergy causing symptoms. Most of the children in the study were between 8 and 10 years old.
Here is a brief overview of the research study:
The main symptoms in the gluten sensitive group included abdominal pain, chronic diarrhea, bloating, failure to thrive (poor growth), vomiting, and constipation. These symptoms were similar to those seen in the group of children with active celiac disease. The “control” group of children with functional (IBS-type symptoms) had only abdominal pain and indigestion as symptoms.
The gluten sensitive children had “extraintestinal” symptoms of tiredness, headaches, and limb pains. Interestingly, these were not seen in children with active celiac disease. The celiac group of children had anemia and elevated liver function enzymes but the gluten sensitive children did not.
Two thirds of the gluten sensitive children had abnormally high antigliadin IgG antibodies (this is an older antibody that was used in the past to assess for celiac disease, but is no longer used because it is non-specific for celiac disease). None of the gluten sensitive children had elevated celiac antibodies (TTG IgA and endomysial IgA). All of the children with active celiac disease had abnormally high TTG IgA and endomysial IgA levels and 13/15 with celiac disease had elevated antigliadin antibodies. The control group kiddos with functional abdominal pain were negative for all antibodies (antigliadin, TTG, and endomysial).
Seven of the 15 children with GS had one of the celiac genes (DQ2/8) and 8 did not. The 8 gluten sensitive children who were DQ2/8 negative all had some combination of HLA DQ1, DQ5, and DQ7.
Eleven of the 15 GS children had an intestinal biopsy while on a gluten-containing diet. All of those with GS had normal to mildly inflamed intestinal mucosa, corresponding to Marsh stage 0 to 1.
In summary, the authors provide findings that support the existence of gluten sensitivity in children as a distinct problem from celiac disease. Children with gluten sensitivity have celiac-like symptoms that resolve on a gluten free diet and return when gluten is reintroduced. Although gluten sensitive children often have elevated antigliadin IgG levels, they have normal TTG IgA and endomysial IgA levels, at least in this study. Their small bowel biopsies show no evidence of villous blunting and, in the majority of cases, the biopsies are normal. In addition, these children’s symptoms are not as a result of being allergic to wheat. Although this is a small study, it is a step in the right direction toward the recognition of non-celiac gluten sensitivity in the pediatric population, and I am thankful that there is finally a research study to support its existence. I am looking forward to being able to read and share similar articles with you.
Francavilla, R., Cristofori, F., Castellaneta, S., et al. Clinical, serologic, and histologic features of gluten sensitivity in children. Journal of Pediatrics. E-pub ahead of print. Nov. 16, 2013
[i]**This is the first guest post on my page by Cristen, an incredibly talented scientist and mother of two children. Her youngest child was diagnosed with Celiac disease earlier this year. Many thanks to Cristen for tackling this challenging topic! [/i][/font][/color][color=rgb(68,68,68)][font='Open Sans']
Celiac is known to have a large genetic component and people with Celiac disease carry the HLA-DQ2 or HLA-DQ8 genes. However, only around 4% of people that carry these genes develop Celiac ([url="http://www.ncbi.nlm.nih.gov/pubmed/20419830"]http://www.ncbi.nlm.nih.gov/pubmed/20419830[/url]). The big question then is, what else is contributing to the development of Celiac?[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Scientists are currently looking at other candidate genes, and so far, seven additional genes that make individuals more susceptible to developing Celiac have been identiﬁed. Genes are a great place to start, but as we all know, gluten is the big culprit in Celiac. It is the known environmental “trigger” for Celiac. Why is it that some people that carry the “Celiac genes” develop the disease after gluten exposure while others don’t?[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Scientists and doctors are asking this question a lot these day. One area that is being investigated is infant feeding. Studies looking back on the Swedish Celiac epidemic of the 1980-1990s have shown that more than half of the epidemic could be explained by infant feeding practices ([url="http://www.ncbi.nlm.nih.gov/pubmed/?term=swedish+celiac+epidemic+review"]http://www.ncbi.nlm.nih.gov/pubmed/?term=swedish+celiac+epidemic+review[/url]). During the time of the epidemic, Swedish infants were being introduced to gluten, on average, at around ﬁve months of age. Breastfeeding ended around this time and was replaced with formula thickened with wheat ﬂour. When breastfeeding averages extended toward seven months and the popularity of wheat-laden formulas decreased, so did the rates of Celiac.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
The Swedish epidemic got researchers thinking about infant feeding and many studies have since been published showing an effect of the age of gluten introduction, the amount of gluten introduced, and breast feeding on Celiac development.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
A new study looking at the effect of these factors on the development of Celiac was recently published in the journal [i]Pediatrics[/i] ([url="http://www.ncbi.nlm.nih.gov/pubmed/24101761"]http://www.ncbi.nlm.nih.gov/pubmed/24101761[/url]). This study, out of Norway, looked at the early feeding practices in 324 children that developed Celiac disease compared to a cohort with 81,843 children that did not develop the disease. The strength of the study is that it was prospective. Unlike most population studies where parents have to look back in time and remember details of early milestones, in a prospective study, parents ﬁll out surveys to provide information in real time.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
So what did this most recent study ﬁnd? The authors found that 3.68/1000 children developed Celiac when introduced to gluten at six months compared to 4.24/1000 when introduced at four months and 4.15/1000 after six months. The increased risk for Celiac disease when gluten is introduced before four months, or after six, has been previously observed ([url="http://www.ncbi.nlm.nih.gov/pubmed/17664902"]http://www.ncbi.nlm.nih.gov/pubmed/17664902[/url]).[/font][/color][color=rgb(68,68,68)][font='Open Sans']
In this new study, the average length of breastfeeding in children that developed Celiac was 10.4 months compared to 9.9 months in the control population. The researchers found a positive association of prolonged (greater than 12 months) breastfeeding and the development of Celiac disease. When all their breastfeeding data was adjusted for confounding factors such as maternal Celiac disease, this increased risk was borderline signiﬁcant. That means that statistically speaking, the data set is on the weaker side and needs to be interpreted with caution. However, it does still demonstrate that in this data set, children that were nursed for twelve months or more had a greater risk for developing Celiac.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
These ﬁndings have been met with frustration by many mothers of children with Celiac. Are women responsible for the development of their child’s Celiac disease because they chose to hold off solid foods and nurse up to, or past, one year? Of course they aren’t, and the authors of this study are not saying that they are. In their discussion, the authors caution that while their data on age of gluten introduction closely matches data from earlier studies, their data on breastfeeding does not.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Many, if not all, previous studies looking at breastfeeding and Celiac disease have found a protective effect from nursing. A 2006 review of the literature found that breastfeeding at the time of gluten introduction provided a 52% reduction in the development of Celiac disease ([url="http://www.ncbi.nlm.nih.gov/pubmed/16287899"]http://www.ncbi.nlm.nih.gov/pubmed/16287899[/url]). In 2005, two Swedish studies found a signiﬁcant reduction in the onset of Celiac in babies that were nursed at the time of gluten introduction and continued to be nursed after that ﬁrst introduction ([url="http://www.ncbi.nlm.nih.gov/pubmed/18806718"]http://www.ncbi.nlm.nih.gov/pubmed/18806718[/url]).[/font][/color][color=rgb(68,68,68)][font='Open Sans']
This latest study found that breastfeeding did not protect against Celiac and that nursing past twelve months increased the risk. Sounds strange right? In their discussion, the authors hypothesize that the greater risk in those breastfed past 12 months may have more to do with gluten than with breast milk. When a child is breastfed longer, the introduction of gluten may be later, after six months of age. Furthermore, since the child is older at gluten introduction, he may be exposed to larger amounts. The authors also mention that some mothers may have nursed longer due to perceived food sensitivities.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
In the end, what is the take away from this study, and others, looking at infant feeding and the development of Celiac? It seems that there may be a window for gluten introduction between 5-6 months. Introduction before and after this time seem to increase the risk of Celiac. As far as breastfeeding, most studies point toward a large protective effect.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
The development of Celiac Disease seems to be a perfect storm of genetic and environmental factors. Factors that may be out of any one person’s control. Studies should continue to look at early infant feeding and disease development, but all data should also be interpreted knowing that as hard as we try, some times, some things just can’t be prevented.[/font][/color]
The second to last session on day one of the 2013 International Celiac Disease Symposium (ICDS) was a talk entitled, “Melting the Celiac Iceberg-potential, latent, silent: to treat or not to treat?” I was very confused about these terms when I first came across them in the Celiac medical and research literature a few years ago.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
[b]“Silent” Celiac Disease[/b] refers to patients who have Celiac Disease (elevated Celiac antibodies on blood testing and abnormal small bowel mucosa on endoscopy and biopsy) but no outward symptoms (or at least, do not appreciate any abnormal symptoms). Many silent Celiacs are picked up when they are screened for Celiac Disease due to having a family member with Celiac Disease and/or being in a high risk category for Celiac Disease, i.e. having Type 1 Diabetes.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
[b]“Latent” or “Potential” Celiac Disease[/b] is the term for when a patient has abnormally high Celiac antibodies on blood testing but either normal, or almost normal, small bowel mucosa on endoscopy. Many with potential Celiac Disease have abnormal symptoms. Some patients with this problem are told they are gluten sensitive, some have been told that they may have “early” or “pre” Celiac Disease, some are told by their doctors that they can continue to eat gluten, and others are advised by their doctors to go gluten free. My understanding is that, in recent years, the word “potential” is preferred over the word “latent” to describe this group.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Dr. Daniel Leffler, from the Celiac Center at Beth Israel Deaconess in Boston, presented the case for the gluten-free diet in patients with potential and silent Celiac Disease, while Dr. Riccardo Troncone, from Naples, Italy, presented the case against the gluten-free diet in these populations. Here are some interesting points that were brought up during both sides of the debate:[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Children with first-degree relatives with Celiac Disease (parents and/or siblings) should be screened for Celiac Disease every 2-3 years in the absence of outward symptoms. Many “silent” Celiacs who think they feel “fine” prior to diagnosis will notice improvement on the gluten-free diet. The presenters reminded us that 60% of newly diagnosed Celiacs have atypical symptoms.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
There are many types of tissue transglutaminase (TTG) antibodies. Type 2 TTG antibodies can attack the placentas of pregnant women, type 3 cause the skin problem of dermatitis herpetiformis, and type 6 can attack the brain and nervous system. As an aside (from another talk during the ICDS), the commercially available assays in the U.S. test for Type 2 only![/font][/color][color=rgb(68,68,68)][font='Open Sans']
There is conflicting information of the risks to silent Celiacs who do not go gluten free. One study in 2006 (Metzger, et al.) showed that untreated silent Celiacs have an increased risk of mortality and cancer over a 10 year period. But another study in 2009 (Lohi, et al) did not show an increase in cancer for this group. As with many areas, more research is necessary.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
According to Dr. Troncone, it is not known if untreated silent Celiac Disease is associated with the development of other autoimmune diseases. He did state that going gluten-free does not improve blood glucose control in patients who have both silent Celiac Disease and Type 1 diabetes.[/font][/color][color=rgb(68,68,68)][font='Open Sans']
Dr. Leffler presented research that shows that up to [b]50%[/b] of potential Celiacs will develop full blown Celiac Disease over a 5 year period and reminded us that TTG antibodies can cause harm even if there are no intestinal changes. He also stated that in order to be diagnosed with “potential” Celiac Disease that one must have an abnormally high TTG antibody level on at least 2 separate occasions (this is to rule out a false positive on the initial test).[/font][/color][color=rgb(68,68,68)][font='Open Sans']
I felt that the take home message from this lecture/debate was that those with silent and potential Celiac Disease should be on the gluten-free diet, but that much more research is needed. Per my notes, they recommended that silent Celiacs should be gluten-free, but it was not explicitly stated that potential Celiacs need to be gluten-free. My concern is that many potential Celiacs may actually have full blown Celiac Disease that was not picked up on biopsy (it was emphasized throughout the conference that many biopsies are not done correctly and that too few samples are taken). I will update all of my ICDS posts once I can get my hands on the power point presentations from the lectures, which I hope is soon! We were unable to take photos of the slides and although I tried to write as quickly as I could, I will add in key information that I may have missed.[/font][/color]
The introductory lecture of the clinical forum of the International Celiac Disease Symposium (ICDS) 2013 in Chicago last week was entitled “Celiac Disease Today: An Overview” given by Drs. Alessio Fasano and Peter Green.
Although the official slides and presentations from the symposium are not yet available for purchase, based on my notes the following topics were addressed during this opening session:
Celiac Disease involves both an innate and an adaptive immune system response to gluten. 1 in 133 Americans have Celiac Disease. The risk of Celiac Disease in 1st degree relatives of Celiac patients (parents, siblings, and children) is 1 in 22. The risk in 2nd degree relatives (aunts and uncles and grandparents) is 1 in 39. Research has shown that the true prevalence of Celiac Disease has increased by 15% in the last few decades. Most people with Celiac Disease (83%) are unaware that they have it…
Although the current “gold standard” for diagnosing Celiac Disease is to perform an endoscopy and small intestinal biopsy, Dr. Fasano did bring up the concept of the “4 out of 5” rule, in which some have proposed that Celiac Disease can be diagnosed if a patient meets at least 4 of the following 5 criteria:
Adverse symptoms when gluten is ingested
Elevated Celiac antibodies on serology (blood tests)
An improvement in symptoms when gluten is removed from the diet
Genetic markers (HLA DQ2 and/or 8, although he did mention that 1-2% of Celiacs are DQ2 and DQ8 negative)
Abnormal small intestinal (duodenal) biopsy
Anti-TTG IgA antibodies are greater than 95% sensitive and 95% specific for Celiac Disease. The DGP IgA antibodies have a sensitivity and specificity of greater than 90%.
No one is born with Celiac Disease and it can develop at any age. Celiac Disease involves a shift from gluten tolerance to an immune (autoimmune) response to gluten. The current thinking is that in order to develop Celiac Disease, one must have a genetic predisposition, ingest gluten, and be exposed to a (yet to be defined) environmental factor. In order to figure out exactly what the environmental factor(s) are, researchers will need to follow a large cohort of children from birth and monitor them for the development of Celiac Disease. We did learn later during the conference that this is actually being done as part of the “Prevent Celiac Disease Study” in Europe, which I will discuss in a later post (www.preventCD.com).
It is now believed that a change in the gut microbiome (bacteria) is involved in the pathogenesis and development of Celiac Disease. Although our gut microbiomes are inherited from our mothers, the composition of our gut bacteria is continually changing. There has been some recent research showing that birth by c-section increases a child’s risk of Celiac Disease by 2-3x. During a normal vaginal delivery newborns’ digestive tracts are colonized by bacteria that they pick up from their mothers’ bodies during labor and delivery. During a c-section this mother to infant transfer of bacteria does not take place.
There are over 70 clinical trials of Celiac Disease going on right now, many of which are currently enrolling subjects. You can check out www.clinicaltrials.gov and search for “celiac disease” for more information.
Dr. Green stated that currently recognized gluten related disorders include Celiac Disease, gluten ataxia, dermatitis herpetiformis, wheat allergy, and non celiac gluten sensitivity (NCGS). NCGS was discussed at the ICDS pre-conference (see my previous post for more details). Celiac Disease can be differentiated from these disorders by the presence of intestinal inflammation and villous atrophy. Based on a 2012 publication, only 17% of people with Celiac Disease have actually been diagnosed. Young men in the age range of 20-30 have the lowest rates of diagnosis.
Currently recognized risk factors for Celiac Disease include formula feeding, being introduced to gluten before 4 months of life or after 7 months of life, being born during the winter months, PPI (proton pump inhibitor, a type a reflux medication) use, and frequent respiratory infections during infancy. Much of this information comes from Sweden, where there was an epidemic of Celiac Disease in children during the 1980s and 1990s which triggered much research and analysis.
We were cautioned of a few pitfalls in the diagnosis of Celiac Disease, many of which I will describe in more detail in future posts. Some of the researchers have found that TTG (tissue transglutaminase) antibody testing from certain labs can be unreliable. Likewise, some research has shown that only 35% of the biopsies performed during evaluations for Celiac Disease are done correctly. Most GI docs take only 2 samples of small bowel, despite the current recommendations that 4-6 samples be taken.
Although Celiac Disease is often associated with digestive symptoms, many patients do not have any symptoms at all (i.e. they are picked up because they are screened due to having a family member with Celiac). Some of the most severe cases of Celiac Disease have been found in patients whose only symptom is anemia (low red blood cell count). On the flip side, a 2009 study showed that only 51% of patients with symptoms of Celiac Disease were actually screened.
A few sort of depressing stats:
-only 20% of patients with Celiac Disease have adequate follow-up after diagnosis
-the average U.S. medical student learns about Celiac Disease for one hour during medical school (I can personally relate to this one!)
And things that I think everyone should know:
-If a patient has dermatitis herpertiformis (DH), then they have Celiac Disease. Dr. Green stated that if one has DH, there is no need for a small bowel biopsy.
-1st degree family members of Celiac Disease patients should be screened every 5 years.
-The Celiac Center at Beth Israel Deaconess Medical Center in Boston has a great new website called “Celiac Now.”
More ICDS information to come soon…Also, any questions are welcome in the meantime!
I spent a good chunk of last Christmas Eve in an MRI scanner, getting my spine analyzed for the white matter lesions of multiple sclerosis (MS). Mike, the MRI technician, piped George Winston’s “December” celiac disease through my MRI headphones, but the music did little to drown out the loud hammering sounds of the MRI and the thoughts that were racing in my head. I prayed and bargained while I was in the scanner, with thoughts such as, “If I do have MS, please let it be relapsing-remitting and not primary progressive,” and, “If I am going to become disabled from MS, please let it happen after my 4 babies have been raised and are out of the house.”
I developed a peripheral neuropathy (nerve damage) last fall, about 2 and a half years after going gluten free for my Celiac Disease diagnosis. In September 2012 I felt better than I had in quite a while and was training for my first half marathon after having Claire in March. Then, the first week of October, I had a pretty bad “glutening” episode (thanks to Trader Joe’s) which took me quite a while to bounce back from. Two weeks later, while visiting family in Boston, I developed persistent numbness and tingling in my hands, feet, tongue, and right upper lip, followed by extreme fatigue and difficulty concentrating/lapses in my short term memory. I went to see a neurologist after my symptoms had persisted for about a week and a half. My full neurologic exam at this point was unremarkable. My brain MRI was normal. I was evaluated for Lyme Disease, lupus, diabetes, sarcoidosis, and several other autoimmune and vascular diseases. My Vitamin B12 and copper levels were normal. My thyroid function was assessed (I have Hashimoto’s Disease and take daily levothyroxine) and everything thyroid-wise was normal as well. My neurologist told me that based on recent research, as well as in his experience, Celiac Disease is the third most common cause of the development of a peripheral neuropathy, behind diabetes and alcoholism. He told me that if my neuropathy was indeed Celiac-related, that it should resolve in 3-6 weeks. And it did. I was out running one day and I finally felt like my feet were back to normal after weeks of running with numb feet (which, looking back, probably wasn't the smartest thing to do!)
We took all gluten out of our home at this point to avoid exposing me to any inadvertent gluten cross-contamination. I stopped eating gluten-free processed foods entirely. But then Thanksgiving came, and I know that I got a hit of gluten somewhere, and about one week later my neuropathy returned to me. I was in the middle of watching my daughter perform in a Christmas ballet routine with Martina McBride and I had a sudden onset of numbness in my hands, feet, tongue, and upper right lip. Again, the symptoms lasted for days which turned into weeks. I returned to my neurologist and he ordered the rest of the testing for multiple sclerosis: a retinal exam to look for optic nerve thinning, visual evoked potentials, and the Christmas Eve spinal MRI, all of which were normal. The numbness and tingling slowly resolved and were gone by New Year's. I was grateful to not have MS.
Since December, I have had the neuropathy symptoms return only twice, once in January and once in July. They have both occurred after traveling, the only time that I am really ever taken out of my gluten free home (aka safe haven) and been exposed to cross-contamination. Fortunately, for reasons that are still unclear to me, my neuropathy symptoms lasted just days, instead of weeks, these last two times.
I started this blog last fall as a way of coping with my new neurologic symptoms from Celiac Disease. I had truly under-appreciated the effects that small amounts of gluten cross-contamination could have on my body until I developed the peripheral neuropathy. Although I did write about the neurologic effects of gluten last fall (see link), I was not prepared to share my personal experience until now.
In conclusion, many patients with Celiac Disease will go on to develop peripheral neuropathies, even while on a gluten free diet. If you have Celiac Disease or non celiac gluten sensitivity and develop symptoms of a possible peripheral neuropathy, please be evaluated by a neurologist to make sure that something treatable, such as a vitamin deficiency or Lyme Disease, is not going on.
For more information on Celiac Disease and peripheral neuropathy, please check out the following links:
1. Peripheral Neuropathy. National Foundation for Celiac Awareness. Accessed 9/10/2013.
2. Celiac Neuropathy. The University of Chicago Celiac Disease Newsletter. Spring 2010. Accessed 9/10/2013.
3. Chin, R. and Latov, N. Peripheral Neuropathy and Celiac Disease. Current Treatment Opinions in Neurology. 2005; 7: 43-48.
I have spent a good portion of this summer enjoying my time with my family, traveling, and not obsessing about celiac disease (which has led me to not write about it either!) Overall, I am comfortable with my gluten free household and life and have accepted my diagnosis. But, the other day, in part due to fatigue and in part due to accidentally eating a KIND bar with soy protein (soy is one of my other food intolerances and I feel like total garbage after eating it), I totally lost my calm. I found my 4-year-old, Gabby, eating a bag of Goldfish crackers when I picked her up from day camp. Instead of hugging and kissing her, and asking her about her day, like I should have, I began to obsess about celiac disease. Thoughts like, “Now I have to clean all of the gluten off of her face and I don’t have any napkins or wet wipes,” and, “Why the heck is she getting Goldfish crackers as a ‘healthy’ snack’?” and, “I cannot afford to get ‘glutened’ this week because I have to be able to work and function as a mom!” went through my mind. The encounter of picking up Gabby from camp quickly became “all about me,” which is one thing that I truly despise about this disease.
That very night I came across a timely article entitled “Everyday Life for Women with Celiac Disease” in which 16 Swedish women with celiac disease share their experiences. Amazingly, there has not been much published on this topic over the years, so I read it with much interest.
Here are some of the common themes that came up in the discussions in the study:
1. Celiac Disease affects a person’s entire life.
2. The experience of persistent fatigue, even after years on the gluten free diet.
3. Many women reported new signs and symptoms in other areas of the body, such as headaches, after starting the gluten free diet.
4. Anxiety about always having to plan ahead to have food to be able to safely eat and frustration at the lack of spontaneity associated with eating outside of the home.
5. Reluctance to attend parties and social events due to fears of gluten contamination.
6. Feelings of sadness, vulnerability, anger, and hopelessness surrounding having to follow the gluten free diet. Many women felt lonely in their struggles.
I have experienced #1-6 more times than I can count, and although it has gotten easier with time, I continue to struggle to explain to others how careful I need to be with eating food that is not prepared in my own kitchen. Many of my friends and family members have had no idea how careful I need to be about cross contamination, and that I have to avoid foods that not only contain gluten, but that are prepared on surfaces and in equipment where cross contamination might occur.
Reading about the experience of these women with celiac disease made me feel much less alone, much less “crazy,” and I realized that my reaction to Gabby’s Goldfish crackers was probably not as severe as I had initially thought. I have decided to be a little easier on myself and move on as I know that Gabby definitely already has. Also, when I pick her up today I’ll be better prepared with some wet wipes and paper towels to clean up the gluten crumbs!
Roos, Suzanne, Hellstrom, Ingrid, Hallert, Claes, and Wilhelmsson, Susan. Everyday Life for Women with Celiac Disease. Gastroenterology Nursing. 2013. 36(4), p. 266-273.
[color=rgb(68,68,68)][font='Open Sans']I have four children, who are all at high risk for developing Celiac Disease. I was diagnosed with Celiac Disease 3 years ago, but have had symptoms since early childhood. My husband does not have Celiac Disease, but he carries one of the two main Celiac genes, DQ2. Due to my children’s risk, I have had their pediatrician screen them when they turn 4 years old with a Celiac panel (blood test with Celiac antibodies). My third child, Gabby, just turned 4 so she will have her first Celiac panel at her well-child visit in a few weeks, along with all of her four year old immunizations. I think I’ll try to get my husband to take her![/font][/color]
[color=rgb(68,68,68)][font='Open Sans']Since starting this page I have had a lot of people ask me if their children should be screened for Celiac Disease. The latest, evidence-based, recommendations for screening are as follows:[/font][/color]
[color=rgb(68,68,68)][font='Open Sans'][b]Children should be screened for Celiac Diease if they have any of the following symptoms:[/b][/font][/color][list]
[*]short or underweight for age, especially if growth has slowed down
[*]diarrhea that lasts for more than a few weeks
[*]recurring constipation, abdominal pain, and/or vomiting
[*]tooth problems called dental enamel defects
[*]iron deficiency anemia that does not respond to treatment with supplements
[color=rgb(68,68,68)][font='Open Sans'][b]“High risk” children who belong to the following groups should also be screened (even if they have none of the above symptoms):[/b][/font][/color][list]
[*]1st degree relative (child or sibling) of someone with Celiac Disease
[*]Type 1 diabetes
[*]Selective IgA deficiency
[*]Autoimmune thyroid disease
[color=rgb(68,68,68)][font='Open Sans']The first step in screening is to have Celiac antibodies measured in the blood. For small children, especially those under the age of 2, it is important for the antibody tests to include the deamidated gliadin peptide, or DGP, antibody. While most Celiac panels include TTG IgA and IgG antibodies and endomysial IgA and IgG antibodies, not all include the DGP antibodies.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']The second step in testing, if Celiac antibodies are abnormal, and/or there are enough symptoms that Celiac Disease is suspected, is to have an endoscopy and biopsy. During the endoscopy a flexible tube with a camera on the end is inserted into the mouth, down the esophagus, and into the small intestine. Small pieces of the small intestine (biopsies) are obtained, which are evaluated by pathologists. In Celiac Disease, the small fingerlike projections (villi) of the walls of the small intestine are flat, or blunted, which impairs the ability of the body to absorb essentials vitamins and nutrients.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']In the absence of symptoms, we are having our kids have Celiac antibody tests every two years or so starting at the age of 4. If any of them develop overt symptoms of Celiac Disease and/or have abnormal antibodies, we will go the route of having an endoscopy and biopsy done to be able to have a firm diagnosis of Celiac Disease. Although we keep a strictly gluten free household, for my sake, as I am very sensitive to any gluten cross-contamination, we do allow our older kids to eat gluten outside of our home. This enables them to have a small “dose” of gluten in their systems on a regular basis. We feel this is important because it enables us to monitor them for symptoms when they do eat gluten and will enable their Celiac blood tests to be as accurate as possible. One of the most common causes of falsely negative Celiac antibody tests is that patients are already gluten free when their tests are performed.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']For more information on Celiac Disease testing I recommend that you check out the [url="http://www.thepatientceliac.com/2013/06/12/should-your-child-be-screened-for-celiac-disease/www.celiaccentral.org/"]National Foundation for Celiac Awarenes[/url]s and the [url="http://www.thepatientceliac.com/2013/06/12/should-your-child-be-screened-for-celiac-disease/www.cureceliacdisease.org/"]University of Chicago Center for Celiac Disease Center[/url] websites.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans'][b]Reference:[/b] Patient information: Celiac disease in children (Beyond the Basics). Authors Ivor D Hill, MD and Anne Roland Lee, MSEd, RD, LD; Section Editor William J Klish, MD; Deputy Editor Alison G Hoppin, MD. Literature review current through: May 2013. [/font][/color]
[color=rgb(68,68,68)][font='Open Sans']There are many of us with celiac disease who develop additional food intolerances after going gluten free. Despite maintaining control of my celiac symptoms by being strictly gluten free, I have become intolerant to soy (2011), sulfites (2012), and too much dairy (late 2012-early 2013). My allergy skin prick tests for soy and milk were negative, which shows that my reactions are not IgE mediated, and, thus, not “typical” food allergies in which there would be a concern about anaphylaxis. I have no knowledge of getting sick from soy, dairy, or sulfites prior to my celiac diagnosis in 2010, however, I may not have realized that I was reacting to these foods because I felt so cruddy from chronic gluten ingestion.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']I have scoured the medical literature and spoken with as many other MDs as I can, and I have found no research or publications that show a link between celiac disease and other food intolerances. There was a nice Italian study published last fall which showed that patients with “wheat sensitive” irritable bowel syndrome (IBS) do have a high incidence of food intolerances, and this led me to the conclusion that many of us with Celiac Disease may also have IBS. Likewise, last month in [i]The American Journal of Gastroenterology[/i], there is a Swedish study (see references) in which the authors describe the multiple food intolerances seen in patients with IBS. The most common culprits for gastrointestinal symptoms in their sample of IBS patients included dairy (49%), beans/legumes (36%), wine/beer (31%), apples (28%), flour (24%), plum (23%), and pork (21%). They reiterate that all of the following foods can precipate digestive symptoms in IBS patients: dairy, foods which are high in FODMAPS (fermentable oligo-, di-, monosaccharides, and polyols), high fat and spicy foods, foods with high levels of biogenic amines, i.e. histamine (such as soy), lectins (present in beans), and preservatives, such as benzoic acid and sulfites.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']Although I do have “IBS” type symptoms after ingesting soy and sulfites, as well as large amounts of dairy, most of my symptoms of food intolerances are in other parts of my body. When I eat soy I develop headaches, nausea, fatigue, flushing, and joint pains. Every time I have developed this constellation of symptoms, I have been able to trace them to accidental soy exposure. With sulfites I develop shortness of breath, wheezing, and flushing right away, followed by headaches, fatigue, joint pains, numbness, “brain fog,” and I overall feel lousy. With suflites I feel very similar to how I feel after being glutened, except when I get glutened I do not have the wheezing or shortness of breath occur.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']So, yes, while I believe that many of us with Celiac Disease have IBS, and that our intermittent digestive symptoms can be attributed to IBS, the real questions are why do so many of us have IBS (leading to additional food intolerances) and what is the real cause for our IBS symptoms?[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']Through reading, doing online research, and discussions with others who I have met through social networking, I think that the answer is [b]histamine.[/b] I believe that some of us with Celiac Disease are experiencing a histamine overload which is waging war on our bodies.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']Histamine is a chemical produced by two types of cells in our bodies: basophils (a type of white blood cell) and mast cells. It is involved in the immune response and is an inflammatory agent. Most of us are familiar with histamine being overproduced in hayfever and other seasonal allergies, and many of us have to take antihistamines, such as Claritin and Zrytec, to decrease allergic symptoms.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']There are many foods which are high in histamine and/or cause histamine to be released. In most cases, the excess histamine produced after eating these foods is either stored or inactivated by the body. However, if one is lacking the enzymes that are responsible for the breakdown of histamine, symptoms can occur. Also, if one has overly active mast cells, too much histamine can be produced, which overwhelms the body. This is called [b]mast cell activation syndrome (MCAS)[/b], and I plan on discussing this topic in my posts in the upcoming months. This is a very newly recognized disorder, and most of the journal articles about MCAS have been published in the last 24 months. It did not exist when I was medical school, so few doctors know about it. Two great resources for mast cell disorders who I have met online who have been very helpful include Yasmina, [url="http://www.thelowhistaminechef.com/"]The Low Histamine Chef[/url], and Dr. Hornet Bupp on [url="https://twitter.com/DrHornetBupp"]Twitter[/url].[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']I will leave you with a list of histamine rich foods to ponder. I found the list interesting, as I have had aversions to many of these foods for as long as I can remember, including pickles, sauerkraut, greek yogurt, sardines, mayo and sour cream. I have also avoided all condiments since I was a young child…[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']Histamine-Rich Foods (including fermented foods):[/font][/color][list]
[*]Alcoholic beverages, especially beer and wine.
[*]Cheeses, especially aged or fermented cheese, such as parmesan, blue and Roquefort.
[*]Cider and home-made root beer.
[*]Dried fruits such as apricots, dates, prunes, figs and raisins (you may be able to eat these fruits – without reaction – if the fruit is thoroughly washed).
[*]Fermented foods, such as pickled or smoked meats, sauerkraut, etc.
[*]Processed meats – sausage, hot dogs, salami, etc.
[*]Smoked fish – herring, sardines, etc.
[*]Sour cream, sour milk, buttermilk, yogurt – especially if not fresh.
[*]Soured breads, such as pumpernickel, coffee cakes and other foods made with large amounts of yeast.
[*]Soy and soy sauce
[*]Vinegar or vinegar-containing foods, such as mayonnaise, salad dressing, ketchup, chili sauce, pickles, pickled beets, relishes, olives.
[color=rgb(68,68,68)][font='Open Sans']Histamine-Releasing Foods:[/font][/color][list]
[color=rgb(68,68,68)][font='Open Sans']Lastly, here is a lovely diagram of mast cells which I am saving here so that I can find it for future posts on mast cell disorders! Image is from [url="http://www.nature.com/nri/journal/v7/n2/full/nri2018.html"]Role of mast cells in allergic and non-allergic immune responses: comparison of human and murine data[/url]. Stephan C. Bischoff. Nature Reviews Immunology 7, 93-104, February 2007).[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']1. Bohn, L., et al. [url="http://www.ncbi.nlm.nih.gov/pubmed/23644955"]Self-reported food-related gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life.[/url] [i]The American Journal of Gastroenterology[/i]. May 2013. 108: 634-641.[/font][/color]
[color=rgb(68,68,68)][font='Open Sans']2. Foods that contain histamine or cause the body to release histamine, including fermented foods. List from Michigan Allergy, Sinus, and Asthma specialists.[url="http://www.michiganallergy.com/food_and_histamine.shtml"]http://www.michiganallergy.com/food_and_histamine.shtml[/url].[/font][/color]
As I was doing my weekly glance through the PubMed database (www.pubmed.gov) I came across an interesting letter to the editor in the Archives of Gynecology and Obstetrics entitled, “Celiac Disease and Endometriosis: What is the Nexus?” Endometriosis is a common gynecologic disorder, which effects approximately 10% of women of childbearing age. It involves the development of endometrium, which is the tissue which lines the uterus, in areas of the body outside of the uterus. Symptoms of endometriosis include heavy menstrual periods, abdominal and pelvic pain, abnormal menstrual cycles, and infertility. Although the exact cause of endometriosis is unknown, theories include retrograde menstruation (endometrial cells from the uterus flow backward into the fallopian tubes instead of out of the body during menstruation), an abnormal placement of embryonic stem cells in the pelvic cavity which produce endometrial tissue, and/or an immune system disorder.
Endometriosis is associated with having the HLA-DQ2 and DQ8 genes (which are also present in approximately 96% of patients with Celiac Disease), as well as the DQ7 gene, which has been associated with Celiac Disease in some southern Italians, Sicilians, and Sardinians.
Two studies published within the last few years have shown associations between Celiac Disease and endometriosis. Researchers in Sweden (Stephansson, et al.) reviewed the medical records of over 11,000 women with Celiac Disease in 2011. Compared with controls, women with Celiac Disease were found to be at a much higher risk of having endometriosis, especially in the first year after diagnosis with celiac disease (overall hazard ratio of 1.39). The authors postulate that there must be a shared inflammatory process in both disorders. Likewise, researchers in Brazil found that 2.5% of women diagnosed with endometriosis also had Celiac Disease (Aguiar, et al, 2009). Please see the references section for links to these two studies.
The gluten free diet has recently been recommended as a strategy to manage the pain of endometriosis. In a pilot study in Italy, 75% of women with endometriosis had a decrease in pain symptoms after 12 months on the gluten free diet (see link in reference section). This strongly suggests that gluten sensitivity and/or Celiac Disease plays a role in endometriosis.
Although I do not have endometriosis, I have interacted with many women through social networking who do have both gluten intolerance and endometriosis. I can say that my periods have become significantly lighter and less painful since going gluten free after my Celiac diagnosis in 2010. I can also say, without a doubt, that my sensitivity to gluten seems to ebb and flow with my menstrual cycle. I seem to be the most sensitive to gluten cross contamination in the 7-10 day stretch before my period, when my estrogen levels are their highest.
With time, I hope that more research is done examining the link between celiac disease and gynecologic disorders. After reading up on endometriosis I did a PubMed search on “Celiac Disease and Polycystic Ovarian Syndrome (PCOS)” and came up with one article from 2002 that was published in Turkey and did not find an association between the two conditions. I have a feeling that if the study was reproduced in the U.S., on a large scale, that an association between Celiac Disease and PCOS would be shown.
For more information on endometriosis, please check out the Mayo Clinic’s website. Rebecca, from “Pretty Little Celiac,” also wrote about endometriosis on her page in January 2013 (see link.)
1. Mormile, R. and Vittori, G. Celiac disease and endometriosis: what is the nexus? Archives of Gynecology and Obstetrics; June 2013 (e-pub, ahead of print).
2. Stephansson, O., Falconer, H., Ludvigsson, J. Risk of endometriosis in 11,000 women with celiac disease. Human Reproduction. 2011; 26 (10): 2896-2901.
3. Aguiar., F., et al. Serological testing for celiac disease in women with endometriosis. A pilot study. Clin Exp Obstet Gynecol. 2009; 36(1): 23-25.
4. Marziali, M. et al. Gluten-free diet: a new strategy for management of painful endometriosis related symptoms? Minerva Chir. 2012 Dec; 67(6): 499-504.
“Up to Date” is an online medical database for physicians and other practitioners. I use it almost every day when I am at work to get a brief overview of the most recent evidence regarding the diagnosis and management of my patients’ problems.
I just reviewed the most recent “Up to Date” highlights on the management of Celiac Disease in adults (published April 10, 2013). Here are some of the highlights:
There are 6 key elements in the management of Celiac patients (note pneumonic CELIAC):
Consultation with a skilled dietician.
Education about the disease.
Lifelong adherence to a gluten free diet.
Identification and treatment of nutritional deficiencies.
Access to an advocacy group.
Continuous long-term follow-up by a multidisciplinary team.
I highlighted #4 because I think that it is in important one to discuss and a reminder that the management of our disease is a bit more complicated than just eating gluten free foods.
The authors suggest that newly diagnosed patients should have blood work done 4 to 6 weeks after starting the gluten free diet, which should include a CBC (complete blood count, to evaluate for anemia), folate and vitamin B12 levels, iron studies, liver chemistries, and Celiac antibody levels. In most cases, TTG (tissue transglutminase) IgA levels should decrease to normal within 3 to 12 months of going gluten free. The authors reiterate that the most common cause of persistently elevated celiac antibodies is continued exposure to gluten (whether intentional or not).
Although the authors still recommend a repeat endoscopy and small bowel biopsy 3 to 4 months after going gluten free, they admit that this is debatable. An increasing number of physicians will only repeat the biopsy for patients with persistent symptoms after going gluten free.
“Nonresponders” are patients who have persistent symptoms and/or elevated antibodies and/or abnormal small bowel biopsies after 2 years on the gluten-free diet. I plan to discuss this topic in further detail in an upcoming post.
The authors recommend monitoring for specific nutritional deficiencies which are associated with Celiac Disease, including the following: iron, folic acid, calcium, vitamin D, thiamine, vitamin B6, vitamin B12, magnesium, zinc, copper, and selenium, especially at the time of diagnosis. This is pretty much in line with the recommendations from the University of Chicago Celiac Disease Center.
Patients should be evaluated for bone loss using a DEXA scan at time of diagnosis and at one year intervals. As an aside, I was unable to get my own insurance to cover this for me, and my out of pocket quotes ranged from $650 to $800. I am going to have to start to pick this battle again soon.
Family members should be screened. The authors quote that 5-11% of first degree relatives (parents, siblings, children) will also have Celiac Disease. This is quite a bit higher than some of the other estimates which I have seen.
A few things in this article which I had never heard before:
- It is normal for women to experience breast tenderness in the 1st 3 months after going gluten free….
- Gluten challenges in children with Celiac Disease may increase the risk of the development of additional autoimmune disorders, such as type 1 diabetes…
- Improvement in dermatitis herpetiformis may not occur for 6 to 12 months after going gluten free…
I just tried to remember what the CELIAC pneumonic stands for, and failed miserably, so I am going to go to sleep instead. Thanks for reading and good night!
“Management of Celiac Disease in Adults.” By Ciclitira, P.J. UpToDate, April 10, 2013. www.uptodate.com.
Nonresponders are the 5% of Celiac patients who have either persistent symptoms and/or abnormally high Celiac antibodies after two years on the gluten free diet.
According the most recent medical review in the “Up to Date” database, there are 5 main categories of nonresponders to the gluten free diet:
-Patient is continuing to eat gluten. This is the most common cause of persistent symptoms. This can be on purpose (i.e. taking a little bite of a gluten containing food every once in a while) or accidental (i.e. not realizing that a child is nibbling her wheat containing Playdough at school).
-Patient doesn’t actually have Celiac Disease. For example, elevated serum antigliadin IgA antibodies may be a false positive. Small intestinal villous blunting may be caused by any of the following: hypogammaglobulinemia, acute infectious gastroenteritis, lymphoma, Crohn’s Disease, and/or a milk protein intolerance.
-There is a second disease present, in addition to Celiac, which is causing symptoms. Lactose intolerance, irritable bowel syndrome, small bowel bacterial overgrowth, pancreatic insufficiency, and microscopic colitis can all lead to digestive symptoms in patients with Celiac Disease. I recently wrote about having the dual diagnosis of Celiac Disease and Irritable Bowel Syndrome (see link).
-Refractory sprue is Celiac Disease which has never improved, or recurs after a period of “remission.” It usually needs to be treated with steroids or other drugs that suppress the immune system, as it can lead to #5.
Ulcerative jejunitis and/or intestinal lymphoma. Patients with ulcerative jejunitis have symptoms of malabsorption, fatigue, loss of appetite, weight loss, abdominal pain, diarrhea, and fever despite being on a gluten-free diet. Small bowel obstructions may occur. Lymphomas have similar symptoms to ulcerative jejunitis, but may also be associated with fevers and abdominal masses.
The bottom line is that If you do not feel significantly better after two years on the gluten free diet, you need to work with your doctor to figure out the reason why. Untreated refractory sprue, ulcerative jejunitis, and lymphoma can lead to death. This is yet another reason to recommend screening to our family members…and if any of my 4 siblings are reading this, yes, you need to get tested or I will continue to badger you about this for this rest of your lives!
1. Cleveland Clinic Center for Continuing Education. “Celiac Disease and Malabsorptive Disorders.” By J. Wakim-Fleming.
2. “Management of Celiac Disease in Adults.” By Ciclitira, P.J. UpToDate, April 10, 2013. www.uptodate.com
If you have Celiac Disease, it is important that you know a bit about your thyroid gland, as you are at a high risk of autoimmune thyroid disease. Experts estimate that between 8 and 12% of people with Celiac Disease have, or will eventually develop, problems with their thyroid gland. Conversely, between 3 and 5% of people with autoimmune thyroid disease will develop Celiac Disease. I was diagnosed with Hashimoto’s Disease (hypothyroidism) in 2003, seven years before my Celiac diagnosis.
The thyroid gland is a butterfly-shaped gland that is present in the neck region, just under the region of the “Adam’s apple,” which is made up of two lobes (see diagram).
Our thyroid glands secrete hormones that regulate metabolism, play a role in the growth and development of our bones and muscles, and impact brain and heart function. Thyroid gland dysfunction can lead to a rapid decline in health. Prior to my diagnosis with Hashimoto’s Disease, I had a 4 to 6 month history of overwhelming fatigue, dry skin, puffiness around my eyes, hair thinning, mental sluggishness, and feeling cold all of the time. I was about to scan and put in a photo of myself in the weeks leading up to my diagnosis, but I look so atrocious that I did not want to scare any of you. It is available upon request!
In Hashimoto’s Disease, the body makes auto-antibodies which lead to thyroid inflammation and destruction, which in turn causes the the thyroid to be under-active (also called hypothyroidism). Hashimoto’s is the most common autoimmune thyroid disease that is associated with Celiac Disease. Common symptoms associated with hypothyroidism include lethargy, depression, muscle cramps, constipation, dry skin, cold intolerance, and/or weight gain. The treatment for hypothyroidism is to take synthetic thyroid hormone, which is called levothyroxine. The brand name for levothyroxine is Synthyroid.
If you are started on levothyroxine, it is important to have your thyroid hormone levels checked frequently, so that your dose can be adjusted as needed. Pregnancy, the postpartum period, lactation, menopause, and other events associated with hormonal changes can also effect the thyroid gland, so it is important to have your thyroid hormone levels monitored closely during these times.
Once I went gluten free, my levothyroxine dose decreased from 150 mcg/day to 125 mcg/day. From the reading that I have done, this is not unusual, and many Celiacs experience a need for less thyroid hormone once off of gluten. However, it is very unusual for hypothyroidism to ever totally resolve. This means that if you are diagnosed with Hashimoto’s Disease, you should anticipate being on thyroid hormone replacement therapy for the rest of your life.
A few other things which I have learned about levothyroxine: 1. Make sure to take it on an empty stomach (I take mine first thing in the morning, about 30 to 45 minutes before breakfast), 2. To take separately from vitamin and mineral supplements, as some can interfere with its absorption, and 3. Make sure that the levothyroxine which you are taking is gluten free. I have been taking generic levothyroxine manufactured by Lannett since October 2012 without any issues. www.glutenfreedrugs.com is a great resource to check out the gluten-free status of drugs and supplements.
Grave’s Disease is the most common cause of hyperthyroidism, or overactive thyroid. In this disease, auto-antibodies stimulate the thyroid gland to produce an excess of hormones. Hyperthyroid symptoms are the opposite of those seen in Hashimoto’s Disease and include weight loss, elevated body temperature, irritability, tremors, heart palpitations, and insomnia. Treatment options for Grave’s Disease include antithyroid medications, radioactive iodine, and surgery. For more on Grave’s Disease, please see the following link (taken from the womenshealth.gov website).
The main test used to screen for thyroid problems and monitor thyroid function is called a TSH (short for thyroid stimulating hormone). In hypothyroidism, the TSH is too high, and in hyperthyroidism, the TSH is too low. In most cases test results should be available within 24 hours of having blood drawn. T4 and T3 levels are also monitored closely during diagnosis and treatment.
My hypothyroid symptoms improved dramatically within one week of starting on Synthroid after my diagnosis with Hashimoto’s Disease. I urge you to have your TSH checked if you or a loved one are experiencing any unusual symptoms which may be due to thyroid dysfunction.
The bottom line is that if you have Celiac Disease, you need to have your thyroid function monitored, and if you have autoimmune thyroid disease, you should strongly consider being screened for Celiac Disease, especially if any concerning symptoms develop.
For more information, please check out the following links:
1. Celiac Disease and Autoimmune Thyroid Disease. Ch’ng, C., et al. Clin Med Res. 2007; 5(3): 184-192.
2. “Celiac Disease, Thyroid Disease Often Found Together. Two Autoimmune Disorders Could Share Common Trigger.” By Jane Anderson, About.com Guide; updated January 19, 2012.
3. “Celiac and the Thyroid.” NFCA website: www.celiaccentral.org. Accessed 04/23/2013.
4. Prevalence of thyroid disorders in untreated adult celiac disease patients and effect of gluten withdrawal: an Italian multicenter study. Sategna-Guidetti C, Volta U, Ciacci C, Usai P, Carlino A, De Franceschi L, Camera A, Pelli A, Brossa C. Am J Gastroenterol. 2001 Mar; 96(3):751-7. See link.
One of my favorite Celiac Disease-related pages on Facebook is that of the University of Chicago’s Celiac Disease Center. One of the first “tidbits” that I read on this page, after discovering it last fall, was the following statement: “Women who have experienced persistent miscarriages or infertility without a known medical cause should be tested for celiac disease.” I had no idea that there was such a strong association between Celiac Disease and infertility until I read this sentence.
I have encountered tons of women, both professionally and personally, who have struggled to get pregnant and/or carry a pregnancy to term. Recent estimates have shown that up to 10.9% of women of childbearing age (15-44) in the U.S. seek treatment for infertility in any given year. I wrote a post about the effects of Celiac Disease on pregnancy in January 2013, and since then have read quite a bit more about topic. Here are some things which I have learned about Celiac Disease and infertility:
-Studies published within the last two years have shown that between 6 and 10% of women with unexplained infertility have (undiagnosed) Celiac Disease. Previously, it was believed that the numbers were much lower, around 2-4%.
-Many women with Celiac-related infertility do have a prior history of irritable bowel syndrome or other GI complaints, but they do not necessarily have these symptoms while undergoing treatment for infertility. It is well known that signs and symptoms of Celiac Disease can appear and then disappear for years (and even decades) before diagnosis.
-It is believed that Celiac impacts fertility due to a combination of malnutrition (nutrient deficiencies interfere with sex hormone function) and the formation of small placental blood clots (thromboses) due to Vitamin B12 deficiency. It has also been shown that anti-TTG antibodies do bind to placental tissues and can interfere with placental formation and function.
-If a woman has infertility due to Celiac Disease, fertility should resume between 3 to 9 months after going gluten free.
-Many researchers conclude that all women with unexplained infertility should be screened for Celiac Disease. Based on discussions with several people, this does not seem to be happening in all parts of the U.S.
The average cost for one cycle of IVF is $12,400. Many women go through multiple rounds of IVF before conceiving. Surrogacy can cost up to $100,000. If the research studies are correct, many women who are paying for these expensive treatments may actually have undiagnosed Celiac Disease. We need to continue to inform and discuss this with our families, friends, and neighbors as so many are potentially impacted.
General infertility statistics are found on the CDC site: [url="http://www.cdc.gov/nchs/fastats/fertile.htm."]http://www.cdc.gov/nchs/fastats/fertile.htm.[/url]
Other references which may be of interest:
1. Undiagnosed celiac disease in women with infertility. Machado AP, Silva LR, Zausner B, Oliveira Jde A, Diniz DR, de Oliveira J. J Reprod Med. 2013 Jan-Feb; 58(1-2):61-6
2. Increased prevalence of celiac disease in patients with unexplained infertility in the United States. Choi JM, Lebwohl B, Wang J, Lee SK, Murray JA, Sauer MV, Green PH. J Reprod Med. 2011 May-Jun; 56(5-6):199-203.
3. Immediate effect on fertility of a gluten-free diet in women with untreated coeliac disease. Raffaella Nenna, Maurizio Mennini, Laura Petrarca, Margherita Bonamico. Gut 2011;60:1023-1024.
4. Anti-tissue transglutaminase antibodies from celiac patients are responsible for trophoblast damage via apoptosis in vitro. Di Simone N, Silano M, Castellani R, Di Nicuolo F, D’Alessio MC, Franceschi F, Tritarelli A, Leone AM, Tersigni C, Gasbarrini G, Silveri NG, Caruso A, Gasbarrini A. Am J Gastroenterol. 2010 Oct; 105(10):2254-61.
5. Infertility Treatment in a Population-Based Sample: 2004–2005. Sara E. Simonsen, Laurie Baksh, Joseph B. Stanford. Maternal and Child Health Journal. May 2012, Volume 16, Issue 4, pp 877-886.
As many of us already know, there are some celiacs who are “refractory” and continue to have ongoing symptoms after going gluten free. In addition, there are a bunch of us who are “super sensitive” in terms of reactions to gluten cross-contamination. I am one of the super sensitives. Not too long ago I had a reaction from eating one bite of a Trader Joe’s “no gluten ingredients” brownie which I had prepared in my own gluten free kitchen for a potluck.
Just last week, Dr. Fasano and colleagues published a research paper on the effects of 3-6 months of a diet of exclusively whole, unprocessed foods on the symptoms of celiac patients who had no improvement while eating strictly gluten free. In this study patients were considered to have non-responsive celiac disease (NRCD) if they failed to respond to the gluten free diet or had a recurrence/relapse of symptoms despite being gluten free. Steroids are currently the standard of care for treating NRCD, which as we know can have serious side effects.
The researchers coined their diet the “Gluten Contamination Elimination Diet.” Here is the breakdown of foods with are allowed and prohibited on this diet:
Allowed: brown and white rice; all fresh fruits and vegetables; fresh meats; fish; eggs; dried beans; unseasoned nuts in the shell; butter; plain yogurt; plain milk, and aged cheeses; oils; vinegar (except flavored or malt); honey; salt. Beverages allowed include 100% juices, water, and Gatorade.
Not allowed: millet, sorghum, buckwheat or any other grains, seeds, or flours; frozen, canned, or dried fruits and vegetables; lunch meats; ham; bacon; seasoned or flavored dairy products; processed cheeses; flavored and malt vinegars.
Basically, all processed foods are eliminated. Of note, dairy is not reintroduced until week 4 of the diet.
17 patients with NRCD, all female, were placed on this diet for an average of 3-6 months. 14 of the 17 (82%) significantly improved on the Gluten Contamination Elimination Diet. Of those who did have biopsies performed after the diet, all but one had resolution of their villous atrophy. This is important information as there have been a lot of recent studies showing that persistent villous atrophy is common in celiac disease. Most of the patients in this study were able to eventually resume a “traditional” gluten free diet.
It has taken me over 3 years, and a lot of trial and error, to figure out the foods which my body loves and hates. Interestingly enough, my body’s food preferences are almost identical to the foods on the “allowed” list in this diet. Had I known about this diet, and adhered to it when I was first diagnosed, it would have saved me a ton of pain and anguish. I am optimistic that this diet (or a similar version) will become the standard of care for those newly diagnosed with Celiac Disease, and I hope that this happens sooner than later. If we work together, we can get the word out!
Reference: “Trace gluten contamination may play a role in mucosal and clinical recovery in a subgroup of diet-adherent non-responsive celiac disease patients.” BMC Gastroenterology. 2013. 13:40 (e-pub).
Yes, this is a real diagnosis, and it effects between 6 to 8% of our population, or approximately 18 million people. Many doctors and patients are unaware that it exists. Most of the papers on this topic have only been published in the last 2-3 years. The British Medical Journal published a case study and review of gluten sensitivity in their November 30, 2012 edition. It is the first case study I have come across in a major medical journal in which a patient self-diagnoses based on information which he found on the internet. The review article gives a good overview of our current understanding of this disorder.
Gluten sensitivity is a catchall term for a bodily reaction to eating gluten. It is not a food allergy, and the autoimmune process differs from celiac disease in that there is not destruction of the villi of the small intestine. People with gluten sensitivity may experience any of the following symptoms after eating gluten:
1. Gastrointestinal symptoms like diarrhea, abdominal pain, constipation, and/or “irritable bowel syndrome.”
2. Fatigue, depression, or difficulty concentrating. Feeling like one has a “foggy brain.”
3. Joint pains, stiffness, and/or leg numbness and tingling.
Anemia and osteoporosis have also been associated with gluten sensitivity. Some recent work has also shown neurologic problems, such as ataxia and peripheral neuropathy, in gluten-sensitive individuals.
Many of these symptoms overlap with celiac disease, but patients with gluten sensitivity do not meet the diagnostic criteria for celiac disease. Some may not have either of the two major celiac genes (HLA-DQ2 or DQ8), some may not have abnormal celiac antibodies, and most have normal, or almost normal, small bowel biopsies.
There are no tests for gluten sensitivity. Once celiac disease has been ruled out, if your symptoms go away when you stop eating gluten, and they return when you start eating gluten again, then you know that you are “sensitive” to it. You can diagnosis yourself.
We do not yet have information on the long-term effects of continuing to eat gluten if you have a gluten sensitivity. In this recent article, Dr. Fasano, one of the leaders in celiac disease research, states that he doesn’t believe that there are long term effects on health if you choose to do this.
I am a bit uncomfortable with this, as just a few decades ago it was believed that patients could “outgrow” celiac disease. The bottom line is that if a food makes you feel terrible, don’t eat it! You can definitely survive and live a full life without gluten-containing cupcakes, pizza, pancakes, etc. My fellow Celiacs and I are proof of this and we can help you on this journey.
For additional reading on this subject I would suggest Melinda Beck’s article, “Clues to Gluten Sensitivity,” published in the March 15, 2011, Wall Street Journal Health Journal. There is also some helpful information about gluten sensitivity on the website www.celiaccenter.org.
I know that this title sounds very boring (so much so that I doubt that many will read any further than this). But, if you can bear with me, there is some fascinating research involving the role of the innate immune system in reactions to wheat. Trust me!
The role of the immune system is to fight infection. There are two main types of immunity: innate and adaptive. The adaptive immune system is highly evolved and involves antibody formation. The ability of our bodies to “remember” previous infections and respond to vaccines depends on adaptive immunity.
The innate immune system, on the other hand, is our first line of defense against bacteria and viruses. It is primitive, exists in all plants and animals, and does not involve antibody formation. The innate immune system is made up of different types of white blood cells, including neutrophils, monocytes, basophils, and mast cells (see picture above). When confronted with an “invader,” these cells release chemicals, called cytokines, which cause widespread inflammation.
The traditional teaching is that autoimmune diseases involve the adaptive immune system, as antibodies are created against one’s own tissues and organs, called “autoantibodies.” For example, in Celiac Disease antigliadin antibodies and tissue transglutaminase antibodies (TTG) are created. However, recent research has shown that the innate immune system may also be involved in the “gluten reaction” experienced in Celiac Disease.
Alpha-amylase/trypsin inhibitors (ATIs) are “pest-resistant” molecules found in wheat and other cereals and grains, such as corn and soy. A team of researchers from Boston and Germany have recently discovered that wheat ATIs trigger an innate immune response, with a release of pro-inflammatory cytokines from monocytes, macrophages, and dendritic cells, when they come into contact with human intestinal cells. They were surprised to find that inflammation occurred when wheat ATIs came into contact with cells from all of the subjects (both with and without Celiac Disease). I find this to be both fascinating and scary.
I am curious to see if those of us with Celiac Disease who seem to be “super sensitives” may actually have a stronger innate immune reaction to wheat than other Celiacs. I am also wondering if the innate immune system plays a role in why so many of us with Celiac Disease develop additional food sensitivities with time and/or feel like we get “glutened” from gluten free foods from time to time. The fact that other grains contain ATIs, and hence, can likely trigger an innate reaction, may explain why so many of us feel our best when we are on a Paleo, or at least “grain-light,” diet. Finally, I hope that this information will stimulate research into the mechanism of non celiac gluten sensitivity, which so many suffer from.
For more information on this subject I suggest the following:
1. Gliadin Triggers Innate Immune Reaction in Celiac and Non-Celiac Individuals. Celiac.com webpage. 12/31/2012.
2. J Exp Med. 2012 Dec 17;209(13):2395-408. doi: 10.1084/jem.20102660. Epub 2012 Dec. Wheat amylase trypsin inhibitors drive intestinal inflammation via activation of toll-like receptor. Junker Y, Zeissig S, Kim SJ, Barisani D, Wieser H, Leffler DA, Zevallos V, Libermann TA, Dillon S, Freitag TL, Kelly CP, Schuppan D. Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
3. Researchers believe pest resistance molecules in wheat play role in triggering innate immune responses. National Foundation for Celiac Awareness website. 12/31/2012.
4. Natural “Pesticides” in Wheat: Is There a Role in Gluten Sensitivity and Celiac Disease? By Peter Olins, PhD. December 19, 2012.
I’ve realized that I have not written for almost a week and I think I am okay with this. When I started this blog two months ago, I anticipated being able to post about once a week, so I think I am on track. Between working full-time, running, and trying to squeeze in some sleep, the main reason that I have not had time is that I have four small children. I am trying my best to cherish this phase of our family life, as I know that someday I will have four teenagers at once!
None of my kids have Celiac Disease, but I consider them all to be at high risk for its development. Although I was diagnosed when I was 33, I have probably had Celiac Disease since early childhood. My mother also has it, and interestingly enough, was diagnosed after I was. Through conversations with aunts and uncles, it seems there is some “gluten sensitivity” in my deceased dad’s family. Although my husband, Tom, does not have Celiac, we do know that he is HLA-DQ2 positive, as he was tested by his GI doctor. He has both an aunt and cousin with Celiac Disease as well. If none of my children go on to develop Celiac Disease, I will be truly amazed!
We started off my Celiac journey with a shared kitchen. I read up on this as much as I could after diagnosis, and I had my own “gluten free” cabinet, pasta strainer and pasta pot, cooking utensils, baking dish, etc. I also kept separate gluten-free butter, peanut butter, and other condiments to avoid cross contamination. I always put my items on a piece of aluminum foil when toasting because I was never able to find the “toaster bags” which people would discuss on the Internet forums. I thought that I was doing everything right and although our gluten-free/non gluten-free set-up did work for a while, I kept on getting sick. In 2012 I developed a peripheral neuropathy, which is persistent numbness and tingling from nerve inflammation, and was evaluated for multiple sclerosis. My neuropathy ended up being Celiac Disease related, as a result of continued exposure to traces of gluten. We made our whole home gluten free in 2012 and I have had minimal problems since then. My exposure to tiny hands and mouths with gluten crumbs was much more damaging than I could ever have imagined when I was diagnosed in 2010.
Through starting this blog I have been able to interact with a lot of moms with Celiac Disease and/or raising kids with Celiac Disease. Many of us have decided to raise all of our kids gluten free, however, this seems to be controversial. I have learned that many people are being advised by their doctors that it is not “safe” to raise their non Celiac children gluten free, because they are being told that by doing so that they are depriving their kids of essential vitamins and nutrients. I have researched this and have not found any evidence that this is the case, as long as gluten free kids are given a wide variety of non-processed, nutrient-rich foods.
Our youngest is now 10 months old and, freakishly enough, has 7 teeth, so she is eating table foods at dinner. We eat a lot of vegetables, fruits, meats, eggs, beans, and fish. Our “starches” consist of potatoes, rice and risotto, squash, and sweet potatoes. Once a week or so we will make a gluten-free pizza of some sort. Lately we have been making a cauliflower pizza crust which I adapted from a recipe I found on Pinterest (I will post it on the “Recipes” page of this blog soon). We occasionally make tacos, enchiladas and other Mexican foods, pasta or lasagna, and Indian dishes, usually a chicken curry of some sort. For snacks our kids eat fresh fruit, applesauce, popcorn, dried fruits and nuts, yogurt, string cheese, gluten-free crackers and rice cakes. We always have a few “treats” in our home, usually Annie’s gluten-free Bunny crackers, ice cream, and a tortilla chip of some sort. I bake a lot of treats for the kids as well. We’ve made delicious chocolate chunk cookies using almond flour 2 or 3 times in the past week (see link). We’ve said goodbye to a lot of convenience foods like chicken nuggets and frozen macaroni and cheese.
I do not see any evidence that my children are nutritionally deprived. They are growing and thriving, are not anemic, and interestingly enough, my two oldest have grown quite a bit since going off of gluten last year. I give all of them a calcium and vitamin D supplement once a day, but I have done this for years. We live in the midwest, where vitamin D deficiency is rampant in both kids and adults, and a deficiency is associated with the development of autoimmune diseases. I have not given them any other vitamins or supplements. I am pretty certain that they are getting enough protein, fat, vitamins, minerals and calories for proper growth and development through their diets.
I am not trying to say that what I am doing for my family is right or best for all families. I am sharing my story in hopes that it may help others to make the decision whether or not to make their entire household gluten free. Looking back, I wish that I would have made the transition much earlier in my journey, as it would likely have prevented me from developing neurologic complications from Celiac Disease. Thank you for reading!
Most of the articles about gluten and celiac disease I’ve came across in the media have focused on symptoms related to digestion, such as abdominal pain and bloating after eating gluten, and damage to the small intestine. The bulk of the gluten-related discussions on the celiac forums I’ve perused concern questions and answers regarding the diagnosis of celiac disease and tips for following the gluten free diet. There have been several papers published over the last few years about the neurologic effects of gluten exposure for those with celiac disease and non-celiac gluten sensitivity. I do not believe that they have gotten the attention that they deserve in the media or on the forums. I am especially interested in this area as over the last few months I have developed a peripheral neuropathy (nerve damage) related to having celiac disease.
Dr. Hadjivassiliou is one of the leading researchers on neurologic problems related to gluten exposure. Although I have no idea how to pronounce his name, I can tell you that he is on faculty in the Department of Neurology at Royal Hallamshire Hospital in Sheffield, United Kingdom. My favorite paper of Dr. Hadjivassiliou’s is a review article titled, “Gluten sensitivity: from gut to brain,” which was published in the Lancet, a major medical journal, in 2010. In this paper, gluten sensitivity refers to both celiac disease and non-celiac gluten sensitivity. Some of the key points of this paper include the following:
• Most patients with neurologic symptoms related to gluten do not have gastrointestinal symptoms.
• Ataxia (a problem with balance and coordination) and peripheral neuropathy (nerve damage) are the most common neurologic symptoms related to gluten. Up to 25% of celiac patients on a gluten free diet will develop a peripheral neuropathy at some point.
• Patients with neurologic symptoms often have celiac “autoantibodies” on blood testing, usually anti-gliadin (AGA) antibodies and/or tissue transglutaminase (TTG) antibodies. Many patients with these antibodies have non-celiac gluten sensitivity, meaning that they have high celiac antibody levels and symptoms, but no evidence of villous blunting (seen in celiac disease) on small bowel biopsy.
• The average age of onset of gluten ataxia is 53 years and for the gluten-related peripheral neuropathy is 55 years.
• Brain MRI findings can include cerebellar atrophy (loss of volume) and/or white matter lesions which may mimic those seen in multiple sclerosis.
• Neurologic symptoms often improve on a strict gluten free diet but may never resolve completely.
Gluten sensitivity has also been associated with seizures, dementia, and migraines. Obviously, further research on the effects of gluten on the brain and nervous system is needed. I’ve came across many people on the celiac forums who have psychiatric symptoms related to gluten exposure as well, although this has not been well-studied.
It seems especially frightening that many people who develop neurologic problems, like me, do so when they are already on the gluten free diet. This is a reminder that even small traces of gluten can cause serious damage to those of us who are gluten sensitive. If you have any family members or friends who develop ataxia or a peripheral neuropathy of an unknown cause, I urge you to recommend an evaluation for celiac disease and non-celiac gluten sensitivity.
For further reading on the this topic I would suggest the following:
1. “Brain Abnormalities Common in Celiac Disease Patients,” by P. Harrison, published in Medscape Neurology News on September 10, 2012.
2. Dr. Hadjivassiliou’s Lancet Neurology article, “Gluten Sensitivity: From Gut to Brain,” published in March 2010.
3. Living Without Magazine article, “Gluten Attack: Ataxia,” found in the Feb/Mar 2011 issue.