Gluten Intolerance & Celiac

This little Question and Answer session on celiac disease and gluten intolerance is actually pretty informative. For example:

Q. Is it possible to be wheat or gluten intolerant, but not have celiac disease?

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A. Dr. Sheila Crowe responds:

Holly, Rose and Jane all touch upon the important issue of how to best treat people with gluten sensitivity or gluten intolerance. Should they all be totally gluten-free or partly gluten-free? And does gluten actually harm them in the long run?

The bottom line is that no one really knows. Part of the problem is that it depends on what type of gluten sensitivity we are dealing with. Another concern is that there are no long-term, rigorously conducted scientific studies to tell us whether a specific diet or another treatment is helpful, harmful or makes no difference to gluten sensitive patients.

We know from many other studies that patients with digestive disorders like irritable bowel syndrome, or I.B.S., often feel better when taking placebos. This makes it difficult to show that a test drug or treatment, such as a gluten-free diet, has a real effect. My clinical experience suggests that quite a few patients with I.B.S. get better on a gluten-free diet, but this can be because of factors other than the harmful effects of gluten.

Gluten can be harder to digest than some other proteins in grains. Going gluten-free, as anyone who has tried this diet knows, eliminates lots of other factors from the diet. Most individuals on a gluten-free diet give up fast-food, prepared foods and packaged foods and instead eat more natural, fresh foods that are often prepared in the home. Feeling better may not necessarily be a result of excluding gluten in this setting. However, gluten may be causing problems in some people.

So how do we know who really needs to be gluten-free?

It depends on the type of patient. Some patients have symptoms of celiac disease but do not have an abnormal intestinal biopsy that is taken before starting a gluten-free diet (by definition, they are not categorized as having celiac disease). If blood tests show that such patients also have antibodies to tissue transglutaminase (TTG) or deamidated gliadin peptide (DGP), I would suggest that these individuals consider going on a truly gluten-free diet, since they are most likely on their way to celiac disease. The same advice could apply to those who have H.L.A. DQ2 or DQ8 genes without elevated antibodies, though in this case the recommendation is more ambiguous, since there are no immune abnormalities or intestinal damage.

Another scenario is the patient without an abnormal intestinal biopsy but who has neurological symptoms and an elevated antigliadin antibody (AGA). These individuals may not ever get celiac disease, but removing gluten from the diet may benefit their neurological problems.

For my patients without intestinal biopsy abnormalities, without celiac disease antibodies (including AGA IgG) and without H.L.A. celiac disease susceptibility (DQ2 or DQ8 genes), I advise a gluten-free diet only to control symptoms. Often these individuals can return to including gluten in their diets.

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It is likely that better defined subgroups of gluten sensitivity will emerge, which will allow us to make clearer recommendations for diagnosis and treatment.