 Understanding Coeliac Disease
 Coeliac disease (CD) was once a term rarely talked about within the general community. Recent statistics from the United States suggest that CD has increased four-fold over the past 50 years; this also appears to be the case in Europe and across many developed countries.
But CD is more than just a case of having to avoid bread; it involves lifelong dietary changes, which can be trickier than you think.
Nutritionist, Leanne Cooper unravels symptoms of CD and some of the challenges that it presents.
What exactly is CD?
CD is a condition that can have a huge impact on a person’s nutrition, health and lifestyle.
It particularly affects the small intestine (SI), which just happens to be one of the most important organs in our body relating to nutritional status.
The small intestine is the part of our intestinal canal, which food ‘spills’ into from the stomach. While digestion largely takes place in the stomach, it continues in the SI. However, the small intestine is the major site of nutrient absorption; and therein lies the root of many of the health issues related to CD.
People with CD react to the gluten contained in wheat, barely, rye and oats (and products containing these as ingredients). In fact gluten (or more specifically gliadin) reacts unusually with the enzymes in the SI causing an inflammatory response; it is this process that causes damage to the lining of the small intestine.
Let’s just review the SI so we can really understand how CD affects health.
The small intestine has a greatly increased surface area because the lining undulates; some describe a healthy small intestine as looking like a shag-pile carpet. The ‘outcroppings’ are called villi and these greatly increase the length and surface area of the SI. The function of these is to allow for increased contact of the food with the absorptive cells of the SI. The end result is that we can absorb as much nutrition as possible from the food we eat.
In those who have CD, the damage that gluten causes leaves the small intestine ‘blunted’. Using the carpet analogy, the shag-pile carpet is reduced to a threadbare carpet.
This leaves us with two main issues:
- Reduced ability to absorb precious nutrients and;
- An ongoing inflammatory process that our body must cope with.
Health implications for those with CD
It’s not hard now to see why CD can cause nutrient deficiencies and failure to thrive (grow) in children; if the organ that is responsible for the majority of nutrient absorption is severely damaged, the amount and quality of nutrients that the body can obtain is significantly impaired. Any compromise of nutrition in life can have short and even long-term effects; this is even more pronounced in those who are still growing, recovering from illness, pregnant or elderly.
Research suggests that malnutrition can impact on mood, fertility, bone health, even your risk of some forms of cancer such as lymphoma; these are very real issues from untreated CD.
How many people suffer from CD?
Estimates put those with CD at about 1 in 100.
What is even more startling is the estimate that some 75 per cent of people with CD are undiagnosed and suffer without even knowing.
Who is at risk and how can it be detected?
CD is more common among Caucasians and West Asians and rare in those of Oriental Asian or Aboriginal Australian background.
Statistics on inflammatory bowel conditions in New Zealand suggest that it is less common in Maori and Pacific Island peoples, and in children is more common among boys than girls (5).
If you have CD then your children have about a 10 per cent chance of also having CD.
In some cases there is a genetic cause for CD, specifically some people inherit genes referred to as the ‘coeliac genes’.
While you can have a test that excludes CD, it isn’t necessarily useful as a marker of being positive for CD because not everyone who has CD has it as a consequence of their genetic makeup.
About every one person in 30 with CD has the genes for CD.
Positive screening tests are often then followed up by a medical procedure to make a diagnosis via sampling of tissue from the small intestine.
Some GPs will opt for a more common blood test for immune compounds that signal a potential reaction to gluten.
Regardless, prior to any diagnostic test, it is recommended the person NOT be on a gluten-free diet.
Why is it on the rise?
To date no-one has a proven explanation for the rise in CD around the world. We humans change our genetic makeup in response to the world quite slowly; it’s been hypothesised that environmental changes to the processing of cereals such as wheat may be in part to blame.
For example, changes to wheat DNA and the methods and compounds used to make wheat products such as bread may be involved. However, surely this poses the question, why is that only certain groups in the community are experiencing sharp rises?
Other suggestions include:
- Changes in the breastfeeding rates
- Bowel and intestinal infections
- Increased wheat intake
- Hygiene and changes to early childhood immunity and exposure to infections (Ref 1)
Don’t be tempted to restrict food intake without help
Any dietary amendment must be undertaken with careful consideration, in particular changes that involve a reduction in variety and food groups.
Anytime something healthy comes out of the diet it should be balanced with something added in. The potential outcome of restricted diets may include reduced nutrient intake, insufficient kJ/energy intake and the development of other food sensitivities from overexposure to a limited range of foods.
All of these are even more important in childhood, given their rate of growth and limited tummy space.
Removing wheat from the diet may well limit thiamin, B2, B3, folate and iron as well as other nutritive compounds.
How do I know if I have CD
It can be a tricky issue to detect, with the signs and symptoms range from severe and very obvious to more subtle and insidious. Also, irritable bowel syndrome can present in a similar way, likewise so too can other food reactions.
Table 1 lists some of the more common symptoms of CD.
Table 1 Symptoms of CD
| Common symptoms in adults |
Common childhood symptoms |
| Anaemia due to poor absorption of iron and nutrients required to produce blood (B12, which is made in the intestines and B9) |
Tummy ache |
| Bloating and wind potentially due to fermentative processes and dysbiosis (imbalance of healthy intestinal bacteria) |
Bloated abdomen and wind |
| Feeling tired and weak |
Large bowel motions often with an awful odour |
| Mouth ulcers from a deficiency of nutrients such as B2 and zinc |
Poor weight gain or unexplained weight loss |
| Nausea and even vomiting |
Irritable, tired, listless behaviour |
| Stomach aches and cramps |
|
| Weight changes, commonly weight loss but it can be weight gain |
|
Coping with CD
While recent studies have reported a ‘safe’ level of gluten intake for those with CD is less than 50mg per day, most agencies advocate the best way forward is avoidance (Ref 2).
CD is not something you can cure, but you can certainly reverse the impact of gluten.
Avoiding gluten, or adopting a gluten-free diet not only allows the SI time to heal, but improves the variety and quality of nutrients the body is able to take up and utilise.
In the long term, this improved nutritional status can have a positive impact on health and vitality.
Now you can probably figure out that standard bread, cakes and pasta contain gluten. People on a gluten-free diet also need to avoid couscous as it is a wheat product, crumpets, muffins and many forms of noodles; however, gluten is one of those little devils that turns up as an unexpected ingredient in all sorts of food, such as foods containing thickeners, stabilisers and flavours.
Gluten-containing foods also include:
- Flavoured crackers, biscuits, corn chips, stocks, drink substitutes
- Foods with filings such as pies and soups
- Some dips and dairy products
- Commercial hot chips
- Foods with thickeners such as icing sugars, sauces, chocolate bars and snacks, lollies
The message is be a good label reader!
Gluten-free options
Foods such as fresh fruit and vegetables, legumes, dairy products and unprocessed oils are great nutritious food options along with fish, chicken and meat all being gluten-free.
Rice, wild rice, millet and corn are common gluten-free options.
Don’t confuse starchy foods with glutagenous foods, for example rice, corn (maize), soya, potato, buckwheat, millet, quinoa, sorghum, amaranth, sago and tapioca are all starchy foods but gluten-free. These foods are good substitutes to ensure nutritional adequacy as well as variety; they are commonly used in gluten-free products.
Sum up The take-home message is to get a positive diagnosis before making any dietary changes, ensure you have good support in amending your diet or your child’s diet to avoid health and nutrition compromises and if you do have to avoid gluten become a good label reader!
Useful links
- http://www.coeliac.co.nz/
- http://www.allergyclinic.co.nz/guides/8.html
- http://www.coeliacsociety.com.au/dis-what.html
References:
- Rubio-Tapia et al, Increased Prevalence and Mortality in Undiagnosed Celiac Disease. Gastroenterology. 2009 July ; 137(1): 88–93.
- Catassi et al. A prospective, double-blind, placebo-controlled trial to establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr 2007;85:160 – 6.
- Pogson, J. Coeliac disease on the rise, Gastroenterology, 2009; 137. 88-93.
- AFGC; Coeliac disease
http://www.ausfoodnews.com.au/2010/10/12/rising-celiac-disease-prompts-new-gf-products.html. Accessed 11/2/11
- Gearry and Day, Inflammatory bowel disease in New Zealand children – a growing problem. J of NZ Med Ass, 2008, 121; 1283.
Words by Leanne Cooper
Director of Cadence Health and qualified nutritionist
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