Celiac Disease

Zachary Hunt

Foundations of Nutrition, Spring 2017

Professor Widdison

Salt Lake Community College

April 5, 2017
 Celiac Disease

Celiac Disease and Nutrition

I was diagnosed with celiac disease at age 16 after years of dealing with gastrointestinal

issues, muscle aches, headaches, and skin disorders. I was taken to many doctors throughout

childhood to try and find the reason for my host of issues. Some diagnoses were made

throughout my childhood, but none that addressed the root of the problem. Eventually a doctor

realized the cause of all my issues and ordered tests that confirmed his suspicions. I had a

diagnosis that answered almost all of the health concerns I was facing. The only known treatment

for the symptoms of celiac disease is to follow a strict gluten-free diet. After following a strict

gluten-free diet for about a year, most of my symptoms had completely dissipated. Ive

continued to eat gluten-free for the past 8 years and experience only mild residual symptoms.

Celiac disease runs in the maternal side of my family. Since I was diagnosed, three other

maternal family members have been diagnosed with celiac disease. This disease impacts my life

and the lives of those around me. This paper presents an overview of celiac disease, symptoms,

diagnosis, genetics, research, and the nutritional concerns of persons with celiac disease.

Celiac Disease Defined

The Celiac Disease Foundation (CDF) defines celiac disease as a serious genetic

autoimmune disorder where the ingestion of gluten leads to damage in the small intestine.

Gluten is a protein found in the grains wheat, barley, and rye. CDF explains that when a person

with celiac disease eats gluten, their body produces an autoimmune response that causes damage

to the villi of the small intestine. Ongoing damage causes improper absorption of nutrients,

leading to further health concerns. It is believed that about 1 in 100 people worldwide have

celiac disease. (CDF)

 Celiac Disease

In my personal experience, Ive found a common misconception exists about celiac

disease; when I tell people that I have celiac disease they often believe it is only a food allergy.

As awareness of celiac disease has has grown over the past few years, Ive noticed this

misconception slowly declining. Celiac disease is much more than just a food allergy, it is an

autoimmune disorder. An article published in the Journal of the American Gastroenterological

Association Institute states that celiac disease is unique in that it is both a food intolerance and

autoimmune disorder. (Rostom, 2006)

Symptoms

According to the National Institute of Diabetes and Digestive and Kidney Diseases

(NIDDK) of the National Institute of Health there are many symptoms of celiac disease. People

with celiac may have a range of symptoms. Some people may experience no symptoms while

others experience many. Some people appear asymptomatic, however the immune response is

still active and doing damage to the small intestine (Rostom, 2006). Gastrointestinal symptoms,

such as bloating, chronic diarrhea, constipation, nausea, gas, and vomiting are more common in

children, but can be seen in adults. Because damage to the small intestine causes malnutrition,

multiple body systems may present further symptoms. Infants with celiac disease may fail to

thrive. Children with celiac disease are more likely to suffer from damage to permanent teeth

enamel, delayed puberty, mood or behavioral changes, short stature, and weight loss. Adults are

more likely suffer from infertility, seizures, fatigue, low bone density, anemia, headaches, itchy

blistery skin (known as dermatitis herpetiformis), and even depression and anxiety. (NIDDK)

Diagnosis
 Celiac Disease

According to the Mayo Clinic, the first diagnostic test that should be used to diagnose

celiac disease is a blood serum test which examines the amount of tissue transglutaminase (tTG)

antibodies in the blood. tTG antibodies are a marker specific to celiac disease. If the results of

the tTG test are high, it is likely that celiac disease may be the cause of the symptoms. However,

this test should not be relied on alone to diagnose celiac disease but rather be used as an indicator

of the need to perform a small intestine biopsy. (Mayo Clinic) A biopsy of the small intestine is

the gold standard diagnostic test for celiac disease. When the biopsies are reviewed by a

pathologist, if a person has celiac disease it will be marked by specific changes or damage to the

lining of the small intestine. If these results are positive, the tTG test may be used to support the

findings of the biopsy. Family history and genetic testing are also important in the diagnosis of

celiac disease. (Rostom,2006)

Genetics

According to an article published in the Journal of Autoimmunity, celiac disease has been

shown to have a strong genetic component (Diell-Crimi, 2015). They state that celiac disease

is not the result of simply ingesting gluten, but the result of a genetic susceptibility and

subsequent ingestion of gluten. This article also cites research which was conducted on

monozygotic (identical) twins. In this study, when one twin was diagnosed with celiac disease,

80% of the time the other twin also had celiac disease. In dizygotic (fraternal) twins, both were

diagnosed less than 20% of the time. (Diell-Crimi, 2015)

Genetic testing can be of some benefit in determining celiac disease risk. Researchers

have found that human leukocyte antigen (HLA) gene alleles HLA-DQ2 and HLA-DQ8 are

strongly tied to the development of celiac disease. When genetic testing is undertaken, the
 Celiac Disease

absence of these alleles indicates that there is no risk of that person having or developing celiac

disease. Celiac disease does not develop in the absence of these alleles. When the genes are

present, it indicates some risk of developing celiac disease. However, most of the people with the

specific HLA genes never develop celiac disease. (Abraham, 2014)

Further Complications

Type 1 Diabetes shares the same genetic allele background as celiac disease, having

HLA-DQ2 and HLA-DQ8 active in people who have been diagnosed with either condition.

(Rostom, 2006). There is extensive research available that confirms a connection between celiac

disease and type 1 diabetes. Around 8% of people with type 1 diabetes are also diagnosed with

celiac disease, compared to 1% of the general population. (Cohn, 2014)

According to the CDF, people with one autoimmune disorder are at a higher risk of

developing another autoimmune disorder. The risk of developing another autoimmune disorder

increases with age of diagnosis; the older a patient is when diagnosed with celiac and treatment

can begin, the higher the risk of developing a second autoimmune disorder. If diagnosed with

celiac between ages 2-4, the risk of developing another autoimmune disorder is 10.5%, compared

to being diagnosed over age 20 when the risk is 34%. (CDF)

In addition to type 1 diabetes and the development of other autoimmune disorders, there

are several more conditions that should be of concern for those diagnosed with celiac disease,

including cancer, osteoporosis, and psychological disorders. An article published in the New

England Journal of Medicine relates that patients with celiac disease have an overall risk of

cancer that is almost twice that in the general population. (Green, 2007) A study on

osteoporosis in North Americans diagnosed with celiac disease found that 75% of celiac patients
 Celiac Disease

had low bone density. After beginning treatment of a gluten free diet, most patients saw some

improvement of bone density measurements after 2 years. (Meyer, 2001) Celiac disease has also

been found to have an effect on depression, anxiety, and fatigue. These conditions may continue

after diagnosis and treatment as a result of dietary restrictions, chronic condition status, and other

related autoimmune conditions. (Zingone, 2015)

Treatment

Currently, the only accepted, available treatment for celiac disease is a strictly followed

gluten-free diet. If a gluten-free diet is strictly followed, over time most people will notice

significant reduction or elimination of symptoms. Eventually, most of the damage in the small

intestine will repair itself. Current tests will not indicate celiac disease in a person who has celiac

disease and has been following a strict gluten-free diet. If gluten is reintroduced, the immune

response will still occur and symptoms will return. (Rostom, 2006)

There is ongoing research in the treatment of celiac disease, giving slight hope of

returning to a normal diet to some people. A company called ImmusanT is currently in the

process of conducting clinical trials of a new immunotherapy drug, Nexvax2. They believe that

Nexvax2 will restore the ability of the immune system to tolerate gluten. The same company is

working on a more advanced method of diagnosing celiac disease that would eliminate the need

for an invasive biopsy of the small intestine. (ImmusanT)

Nutritional Challenges and Counseling

There are several nutritional deficiencies that can develop either as a result of the disease

process or as the result of maintaining a gluten free diet. Careful planning and monitoring is

needed to reduce the risk of developing a harmful deficiency. A dietitian can help monitor and
 Celiac Disease

assess a person with celiac disease to provide nutritional advice and follow up treatment.

(Wierdsma, 2013)

A study published in the Nutrients Journal found that almost 90% of celiac patients had at

least one nutrient deficiency at the time of diagnosis. The researchers found that celiac patients

most often had a deficiency of one or more of the following nutrients at diagnosis; vitamin A,

vitamin B6, folic acid, vitamin B12, or zinc. Almost 32% of study participants were found to

have anemia and 46% had decreased iron storage. 17% of patients were considered malnourished

while another 29% were overweight. (Wierdsma, 2013)

Christen Cooper, MS, RD had this to say about a dietitian's role in the treatment of celiac

disease; Because food is at the center of not only reversing the past damage to the intestine but

also preventing future damage, dietitians can promote health and healing to patients through their

support and guidance. Cooper also suggested that dietitians have a crucial role in coaching

patients through what can be a shocking, frustrating time. (Cooper, 2012)

Maintaining a gluten-free diet can sometimes be a difficult task. At first, many people

may feel overwhelmed by the prospect of eating a gluten-free diet for life. Many staples of the

American diet rely heavily on the use of wheat, barley, and rye, all of which contain gluten.

According to an article published in the New England Journal of Medicine, many people may

find it difficult to adhere to the gluten-free diet for social, economic, or personal reasons. They

may also find it difficult because of the high cost and low palatability of gluten-free foods.

People may also struggle due to inadequate education and inadequate follow-up with physicians

and dietitians. (Green, 2007)

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While wheat, barley, and rye products should be strictly avoided, there are several

substitute flours that can be used. This same study said the following; Because the substitute

flours are not fortified with B vitamins, vitamin deficiencies may occur; they have been detected

in patients who are on the diet for a long time (more than 10 years). Therefore, vitamin

supplementation is advised. Meats, dairy products, and fruits and vegetables are naturally

gluten-free and help to make for a more nutritious and varied diet. (Green, 2007)

Conclusion

Celiac disease is an autoimmune disorder with no known treatment other than a strictly

adhered to gluten-free diet. If a gluten-free diet is not followed, damage to the small intestine

will continue and nutritional deficiencies can occur. When a person with celiac disease is

properly educated and motivated, they can see significant improvement in symptoms, often

leading to an improved, mostly symptom free, quality of life. They should continue to be

regularly assessed, both medically and nutritionally, to ensure nutritional health. New and

ongoing research may provide advancements in the treatment and quality of life of people with

celiac disease. For now, seeking to maintain a balanced and nutritious gluten-free diet is the best

course of action for anyone diagnosed with celiac disease.

 Celiac Disease

References

Abraham, G., Tye-Din, J. A., Bhalala, O. G., Kowalczyk, A., Zobel, J., & Inouye, M. (2014). Accurate and Robust Genomic
Prediction of Celiac Disease Using Statistical Learning. PLoS Genetics,10(2). doi:10.1371/journal.pgen.1004137

Celiac Disease Foundation. (n.d.). Associated Autoimmune Disorders, Conditions, and Cancers. Retrieved April 05, 2017, from
https://celiac.org/celiac-disease/understanding-celiac-disease-2/celiac-disease-and-comorbid-conditions/22514-2/

Celiac Disease Foundation. (n.d.). What is Celiac Disease? Retrieved April 04, 2017, from
https://celiac.org/celiac-disease/understanding-celiac-disease-2/what-is-celiac-disease/#AJvkDifaHDorBTsU.99

Celiac Disease Foundation. (n.d.). What is Gluten? Retrieved April 04, 2017, from
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Cohn, A., Sofia, A. M., & Kupfer, S. S. (2014). Type 1 Diabetes and Celiac Disease: Clinical Overlap and New Insights into
Disease Pathogenesis. Current Diabetes Reports,14(8). doi:10.1007/s11892-014-0517-x

Cooper, C. C., MS, RD. (2012, May). Gluten Free and Healthy - Dietitians Can Help Reverse Nutrition Deficiencies Common in
Celiac Disease Patients. Retrieved April 05, 2017, from http://www.todaysdietitian.com/newarchives/050112p24.shtml

Dieli-Crimi, R., Cnit, M. C., & Nez, C. (2015). The Genetics of Celiac Disease: A Comprehensive Review of Clinical
Implications. Journal of Autoimmunity,64, 26-41. doi:10.1016/j.jaut.2015.07.003

Green, P. H., & Cellier, C. (2007). Celiac Disease. New England Journal of Medicine,357(17), 1731-1743.
doi:10.1056/nejmra071600

ImmusanT. (n.d.). About ImmusanT. Retrieved April 05, 2017, from http://www.immusant.com/about/overview.php

Mayo Clinic Medical Laboratories. (n.d.). Tissue Transglutaminase (tTG) Antibody, IgA, Serum. Retrieved April 05, 2017, from
http://www.mayomedicallaboratories.com/test-catalog/Clinical and Interpretive/82587

Meyer, D., Stavropolous, S., Diamond, B., Shane, E., & Green, P. H. (2001). Osteoporosis in a North American adult population
with celiac disease1. The American Journal of Gastroenterology,96(1), 112-119.
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National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (n.d.). Symptoms & Causes of Celiac Disease .
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Wierdsma, N., Marian Van Bokhorst-De Van Der Schueren, Berkenpas, M., Mulder, C., & Bodegraven, A. V. (2013). Vitamin
and Mineral Deficiencies Are Highly Prevalent in Newly Diagnosed Celiac Disease Patients. Nutrients,5(10),
3975-3992. doi:10.3390/nu5103975

Zingone, F., Swift, G. L., Card, T. R., Sanders, D. S., Ludvigsson, J. F., & Bai, J. C. (2015). Psychological morbidity of celiac
disease: A review of the literature. United European Gastroenterology Journal,3(2), 136-145.
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