Is your bloating and abdominal pain related to gluten?
“Gluten disease” are keywords commonly searched for by those seeking health information related to gluten related disorders. Celiac disease and gluten related disorders can be complicated topics. Here you will find the the basics for what you need to know. Gluten-related disorder is a term used to include all gluten diseases triggered by gluten consumption. Gluten related disorders result from an immune system response to wheat gluten, (a protein in wheat with elastic properties). Gluten disease may occur as a severe condition with malabsorption or as a mild disease in the form of sensitivity. Both genetic makeup, diet, and environmental factors lead to gluten-related disorders. The widespread use of wheat gluten in a large number of food sources over long term by modern society has contributed to a significantly higher incidence of gluten-related disorders in recent years.
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A gluten-related disorder may occur in any age group as either gastrointestinal symptoms, as non-gastrointestinal symptoms, or a combination of both. A gluten free diet will improve gluten intolerance symptoms and gluten sensitivity. Read further for a list of gluten free foods in the gluten free diet plan listed below. According to the Mayo Clinic, the incidence of gluten disease and celiac disease has increased four-fold since 1950 and significantly increases the risk of mortality and gastrointestinal cancer if left untreated (1). Gluten disease and gluten-related disorder are more common in patients of northern European descent than other ethnic backgrounds.
Symptoms of Gluten Disease:
Symptoms of gluten related disorder may be difficult to separate from other gastrointestinal illnesses, and include diarrhea, constipation, weight loss, weight gain, abdominal bloating, malodorous stool, and abdominal pain. Gluten disease may also cause extraintestinal health problems such as bone demineralization, osteoporosis, joint pains, weight gain, weight loss, elevated liver function tests, enamel defects, apthous stomatitis, lower birth weights, poor childhood weight gain, hypocalcemia, fatigue, weakness, dry skin, blistering rash, eczema, iron deficiency anemia, infertility, microscopic colitis, pancreatic exocrine dysfunction, depression, neuropathy or numbness of the extremities, cerebellar ataxia, epilepsy, dementia, and headaches. The tongue is also commonly affected with soreness, burning, redness or atrophy. Infrequent diarrhea plus tongue symptoms have often led to a diagnosis of celiac disease (3).
The Difference Between Celiac Disease and Gluten Sensitivity
According to Ludvigsson JF, et al (2) classic celiac disease or celiac sprue is characterized specifically as symptoms of malabsorption, failure of growth, diarrhea, poor fat absorption and/or weight loss. The authors recommended that gluten sensitivity be renamed as non-celiac gluten sensitivity. Those with non-celiac gluten sensitivity may have many similar but more mild symptoms than celiac disease. These individuals have an immune response to gluten, but do not have the elevation in transglutaminase (TTG) antibodies or the pathologic changes of celiac disease present within the bowel walls on a biopsy. There is no current standard diagnostic test for non-celiac gluten sensitivity, nor is there a method available to measure a immune response.
Gluten Related Disorder Screening:
According to Rubio-Tapia A et al (4) patients should be evaluated for celiac disease if there are:
- Signs or symptoms of malabsorption
- Lab testing with signs of malabsorption
- Signs or symptoms with a 1st degree relative who has gluten disease
- Unknown increase in liver function tests
- Diabetes mellitus type 1 with signs or symptoms of malabsorption
Diagnosis of Gluten Disease and Gluten Related Disorders
Proper diagnosis may be complicated and is best accomplished by the primary care physician and gastroenterologist. Celiac disease should not be self-diagnosed by patients since the condition has non-specific symptoms which require to be distinguished from other gastrointestinal conditions. If a patient is believed to have symptoms of celiac disease, testing should ideally be done while on a diet containing gluten.
The initial test is immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody in patients over 2 years old. It is positive in about 98% of individuals with celiac disease and negative in about 95% of those without celiac disease (19). If this serology is positive, one should proceed to an endoscopic small bowel biopsy of the duodenum. If a patient has a typical symptoms and high probability of celiac disease, the physician may advise to proceed directly to a small bowel biopsy. A positive biopsy will have a pathology showing lymphocytes within the epithelium, hypertrophy of crypts, and diminished villous height. A genetic test is also available which determines susceptibility of the patient to celiac disease.
Additional testing of routine complete blood count may show anemia and nutrient testing might reveal vitamin and mineral deficiencies. Basic metabolic panel may show electrolyte abnormalities related to malabsorption. Liver function tests may be elevated.
Genetic testing for risk of celiac disease may be done using blood or a swab from the inside of the cheek. About 95% of individuals with celiac disease have the HLA DQ2 gene and about 5% of individuals with celiac disease have the HLA DQ8 gene. These 2 genes are present in up to 40% of the population. However, only 3% of these individuals with the genes will develop celiac disease. If the individual does not have these genes, celiac disease is extremely unlikely.
The Dillemma Of Diagnosing Gluten Related Disorders
Gluten antibody testing will help diagnose gluten related disorder if symptoms are related to gluten disease. If gluten disorder is present, the symptoms will get better with eliminating all sources of gluten. One can consider eliminating gluten to see if symptoms get better. However, if this testing is done after eliminating gluten, the antibody levels will decrease and the test may return negative. All tests for gluten disease require that the person be actively consuming gluten daily for 12 weeks to be accurate. Those who wish to be tested for gluten related disease already on a gluten-free diet will need to be placed on a gluten challenge for 12 weeks prior to having the testing done.
Eating Meat From Grass Fed Animals Compared to Grain Fed Animals
Many individuals report that eating meat from grass fed animals as opposed to meat from grain fed animals have fewer symptoms. The reasons for this are not well understood and symptoms may be due to a number of other factors. There is no quality research to date comparing the symptoms in those who eat meat from grass fed vs. grain fed animals. Meats from grain fed animals may be eaten by those with celiac disease Grass fed animal meats may be more healthy and demand a higher market price, Both grain fed and grass fed animal meats unlikely contain any significant amount of gluten unless some is added during the preparation or cooking process.
Gluten Associated with Inflammation
Individuals often choose to eliminate gluten from their diet because it is one of the many factors which have a role in autoimmune disease and chronic inflammation. Gluten consumption is associated with elevations of C-reactive protein, interleukin, interferon, and tumor necrosis factor, all of which are cytokines responsible for inflammation (18). Research is building to demonstrate how inflammation may result from gluten and other dietary factors which is implicated in many disease processes.
Gluten Free Diet for Gluten Disease and Gluten Related Disorders:
Once diagnosed with a gluten-related disorder, treatment is focused on elimination of all sources of gluten from the diet. Even small amounts of residual gluten in the diet are known to contribute to the celiac disease process. Dietary counseling is based on support of the patient in the major lifestyle change of a gluten-free diet for life. This is best accomplished by a qualified dietitian. Eliminating gluten in the diet is advocated by many for the implication
Adherence may be difficult due to the large variety of processed foods in the U.S. which contain gluten. Education is required to avoid all foods containing wheat, rye, barley (including all types of beer), and oats. Distilled alcohol beverages and wine are generally free of gluten. Patients should be counseled to avoid occult sources of gluten in foods. Gluten containing foods should be substituted for corn, rice, soy, buckwheat, beans, vegetables, fruits, nuts, tapioca flour, rice, potatoes, and lean meats. Oat consumption is controversial, with research showing that oats may provoke gluten related disorder, while other research has supported oats as generally safe to consume. It may be best to avoid oats if intolerance to oats is suspected.
The Gluten-free Diet Plan for Celiac Disease and Gluten Related Disorders:
- Even small amounts over 1-2 grams of residual gluten in the diet are known to contribute to the celiac disease process (inflammation due to gluten). Gluten sensitive individuals are able to tolerate up to 5 grams of gluten without symptoms of sensitivity. The general guideline is that anything containing wheat contains gluten.
- Dietary counseling is based best accomplished by a qualified dietitian to provide support for a major lifestyle change with a gluten-free diet for life
- Education is necessary to avoid all foods containing wheat, rye, barley (including all types of beer), and oats. Avoid these gluten containing foods.
- Distilled alcohol beverages and wine are generally free of gluten.
- Gluten containing foods should be substituted with the following gluten free foods (Yes, these foods are OK to eat):
- Grains including rice, corn, quinoa, soy, and buckwheat
- Acceptable flours include tapioca, rice, potato, corn, millet, sorghum, amaranth, and coconut
- Meats without coatings or additives which include beef, bacon, pork, chicken, and turkey.
- Fish and shellfish without coatings or additives.
- Fresh or frozen fruit without additives.
- Nuts and seeds
- Vegetables, beans, herbs, spices, and coconut.
- Gluten free pasta is available containing rice, quinoa, and corn
- Pay special attention to labels for retail and processed foods and avoid those with labels which include gluten, wheat protein, and vital wheat protein as ingredients.
- Oat consumption is controversial, with research showing that oats may provoke gluten related disorder, while other research has supported oats as generally safe to consume
References for Gluten Disease and What You Need to Know
1.Celiac disease: On the rise. Discovery’s Edge. Mayo Clinic’s Online Research Magazine. July 2010. Accessed 5/17/2014. http://www.mayo.edu/research/discoverys-edge/celiac-disease-rise
2.Ludvigsson JF, Leffler DA, Bai JC, Biagi F, Fasano A, Green PH, Hadjivassiliou M, Kaukinen K, Kelly CP, Leonard JN, Lundin KE, Murray JA, Sanders DS, Walker MM, Zingone F, Ciacci C.The Oslo definitions for coeliac disease and related terms. Gut. 2013 Jan;62(1):43-52. http://www.ncbi.nlm.nih.gov/pubmed/22345659
3.Pastore L, Lo Muzio L, Serpico R. Atrophic glossitis leading to the diagnosis of celiac disease. N Engl J Med. 2007 Jun 14;356(24):2547. http://www.ncbi.nlm.nih.gov/pubmed/17568041
4.Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA; American College of Gastroenterology. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013 May;108(5):656-76; quiz 677. http://www.ncbi.nlm.nih.gov/pubmed/23609613
5.M. Potts, B. Bellows, “Autism and Diet”. J Epidemiol Community Health. 2006 May; 60(5): 375. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563974/
6.Mulloy A, Lang R, O’Reilly M, Sigafoos J, Lancioni G, Rispoli M. Gluten-free and casein-free diets in the treatment of autism spectrum disorders: a systematic review. Research in Autism Spectrum Disorders 2010; 4(3): 328-339. http://www.edb.utexas.edu/education/assets/files/ltc/gfcf_review.pdf
7.“The gluten-free, casein-free diet in autism: results of a preliminary double blind clinical trial.” College of Nursing, University of Florida, Gainesville, 32610, USA. http://www.ncbi.nlm.nih.gov/pubmed/16555138
8.“Gluten- and casein-free diets for autistic spectrum disorder.” Cochrane Database Syst Rev. 2004:92):CD003498. http://www.ncbi.nlm.nih.gov/pubmed/15106205
9.“Food allergy and infantile autism” Department of Paediatrics(sic), University of Rome Las Sapienza, Itally. Panminerva Med. 1995 Sep; 37(3): 137-41. http://www.ncbi.nlm.nih.gov/pubmed/8869369
10.Cascella NG1, Santora D, Gregory P, Kelly DL, Fasano A, Eaton WW. Increased prevalence of transglutaminase 6 antibodies in sera from schizophrenia patients. Schizophr Bull. 2013 Jul;39(4):867-71. http://www.ncbi.nlm.nih.gov/pubmed/22516148
11.Lucendo AJ, García-Manzanares A. Bone mineral density in adult coeliac disease: an updated review.Rev Esp Enferm Dig. 2013 Mar;105(3):154-62. http://www.ncbi.nlm.nih.gov/pubmed/23735022
12.Mazure R, Vazquez H, Gonzalez D, Mautalen C, Pedreira S, Boerr L, Bai JC. Bone mineral affection in asymptomatic adult patients with celiac disease. Am J Gastroenterol. 1994 Dec;89(12):2130-4. http://www.ncbi.nlm.nih.gov/pubmed/7977227
13.Trotta L, Biagi F, Bianchi PI, Marchese A, Vattiato C, Balduzzi D, Collesano V, Corazza GR.Dental enamel defects in adult coeliac disease: prevalence and correlation with symptoms and age at diagnosis. Eur J Intern Med. 2013 Dec;24(8):832-4. http://www.ncbi.nlm.nih.gov/pubmed/23571066
14.El-Hodhod MA, El-Agouza IA, Abdel-Al H, Kabil NS, Bayomi KA. Screening for celiac disease in children with dental enamel defects. ISRN Pediatr. 2012;2012:763783. http://www.ncbi.nlm.nih.gov/pubmed/22720168
15.Shakeri R, Zamani F, Sotoudehmanesh R, Amiri A, Mohamadnejad M, Davatchi F, Karakani AM, Malekzadeh R, Shahram F.Gluten sensitivity enteropathy in patients with recurrent aphthous stomatitis. BMC Gastroenterol. 2009 Jun 17;9:44. http://www.ncbi.nlm.nih.gov/pubmed/19534771
16.Peters SL, Biesiekierski JR, Yelland GW, Muir JG, Gibson PR. Randomised clinical trial: gluten may cause depression in subjects with non-coeliac gluten sensitivity – an exploratory clinical study. Aliment Pharmacol Ther. 2014 May;39(10):1104-12. http://www.ncbi.nlm.nih.gov/pubmed/24689456
17.van Hees NJ, Van der Does W, Giltay EJ. Coeliac disease, diet adherence and depressive symptoms. J Psychosom Res. 2013 Feb;74(2):155-60. http://www.ncbi.nlm.nih.gov/pubmed/23332531
18.de Punder K, Pruimboom L. The dietary intake of wheat and other cereal grains and their role in inflammation. Nutrients. 2013 Mar 12;5(3):771-87. http://www.ncbi.nlm.nih.gov/pubmed/23482055
19. Celiac Disease Foundation. Screening. Accessed 9/6/2016. https://celiac.org/celiac-disease/understanding-celiac-disease-2/diagnosing-celiac-disease/screening