An estimated 1% of the global population has Celiac disease. Even more alarmingly, this percentage is growing, with incidence rates increasing an average of 7.5% per year for the past several decades, according to the Celiac Disease Foundation and the National Institute of Diabetes and Digestive and Kidney Diseases.
For me, the rise in rates is personal. My wife, Amy, was diagnosed with celiac disease after her last pregnancy. As I have written, this was one of several events after a long career in emergency medicine which led me to want to explore integrative medicine.
In Amy’s case, the symptoms arose after she gave birth to our youngest son. But several traditional doctors told her that the joint pain and profound fatigue she was feeling were in all probability related to being an “old mom.” Finally, a nutritionist suggested she might have developed Celiac disease. Six weeks later, after experimenting with going gluten-free, her symptoms had disappeared.
So, this topic is close to my heart.
In this article, I will explore:
The differences between celiac disease and gluten sensitivity
The role of gliadin, the protein behind reactions to gluten
Whether how we grow wheat has anything to do with the rise in prevalence
Connections with leaky gut syndrome
The perspective of gastroenterologists on celiac disease
Let’s get started.
Understanding Celiac Disease and Gluten Sensitivity
Celiac affects about 1 in 133 Americans. However, recent screening studies have pointed to potentially higher prevalence rates in certain countries, such as 1.6% in Italy and 1.99% in Finland. The prevalence of celiac disease varies with sex, age, and location, with higher rates among women and children compared to men and adults.
So what is celiac disease? It is a serious autoimmune disorder, occurring in genetically predisposed individuals, where the ingestion of gluten leads to damage in the small intestine. The damage caused by this immune reaction leads to the malabsorption of nutrients and a wide range of symptoms, including digestive issues, fatigue, and joint pain.
The only truly effective treatment for celiac disease is a strict gluten-free diet.
Celiac disease is distinct from gluten sensitivity, which may affect 2-4% of people. Gluten sensitivity does not damage the intestines but can cause discomfort and symptoms similar to celiac disease, including abdominal pain, bloating, and headaches, but without the autoimmune response.
Diagnosing Non-Celiac Gluten Sensitivity (NCGS) can be challenging as there are no specific tests; it's typically identified by ruling out celiac disease and wheat allergy.
Importance of Accurate Diagnosis
Differentiating between celiac disease and gluten sensitivity is crucial for effective management. This is where functional and integrative medicine approaches thrive, whereas the siloed approaches found in traditional medical specialties may fall short.
For those with celiac disease, even small amounts of gluten can cause significant health issues. In contrast, individuals with gluten sensitivity may tolerate small amounts of gluten without severe consequences. However, accurate diagnosis through blood tests, endoscopy, or dietary assessment is essential for appropriate treatment and dietary recommendations.
The Role of Gliadin in Gluten Reactions
Gliadin, a component of the gluten protein, is often the trigger for the immune response seen in celiac disease and the discomfort in gluten sensitivity. Understanding gliadin is key to comprehending how these conditions develop. Gliadin, when consumed, can cause an immune reaction in susceptible individuals, leading to the symptoms associated with these disorders.
Unpacking the Complex Science
The relationship between gluten, gliadin, and immune responses is intricate and still a subject of ongoing research. Understanding this complexity is essential for developing effective management strategies for celiac disease and gluten sensitivity. It's not just about avoiding gluten; those of us in integrative medicine seek to understand the underlying mechanisms that cause the body to react to gliadin.
It could be a problem due to several factors, including changes in wheat composition, increased consumption of wheat products, altered gut flora due to antibiotic usage, and a cleaner environment leading to overreactions by the immune system. Additionally, the overuse of antibiotics and highly processed foods containing wheat gluten are also thought to contribute to the rise in gluten intolerance. Furthermore, some studies have linked gluten to a wide range of health issues, including mood and neurological diseases.
That said, there is still much disagreement. As a 2018 article in Science noted, “Some researchers are convinced that many patients have an immune reaction to gluten or another substance in wheat.”
But there is also another camp:
Others believe most patients are actually reacting to an excess of poorly absorbed carbohydrates present in wheat and many other foods. Those carbohydrates—called FODMAPs, for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols—can cause bloating when they ferment in the gut. If FODMAPs are the primary culprit, thousands of people may be on gluten-free diets with the support of their doctors and dietitians but without good reason.
Unfortunately, some of the studies on the topic are either difficult to conduct—i.e., placing cohorts of patients on blinded diets so they don’t know whether they’re eating gluten or not (these showed gluten sensitivity is not psychosomatic)—while other studies are difficult to replicate or show marginally conclusive results.
Differences in Wheat Cultivation
The way we grow and harvest wheat can influence the gliadin content in gluten. Modern agricultural practices, including the use of certain pesticides and cultivation methods, have been suggested to affect the structure of gluten, potentially making it more reactive to the immune system. This change in gliadin composition could be a contributing factor to the increasing prevalence of gluten-related disorders.
The variation in wheat cultivation between the United States and Europe is one of the intriguing aspects of gluten-related disorders. The types of wheat grown, as well as the methods of cultivation and processing, differ significantly. European wheat tends to have a different composition of gluten compared to its American counterpart, which might influence the reactivity of individuals with gluten sensitivity or celiac disease.
But even though Americans like to blame their factory farm system for a range of on-the-rise disorders, in this case, there is actually a higher prevalence of gluten sensitivity in Europe than in the U.S., and research also shows a higher incidence of gliadin there.
One of those more interesting recent studies came when a team of researchers used an extensive seed archive from the Leibniz Institute of Plant Genetics and Crop Plant Research to test whether gliadin has increased globally over time:
From the archive, the researchers selected five leading wheat varieties for each decade of the 120 years examined. In order to generate comparable samples, they cultivated the different varieties in 2015, 2016 and 2017 under the same geographical and climatic conditions.
Analyses by the team of scientists showed that, overall, modern wheat varieties contain slightly less protein than old ones. In contrast, the gluten content has remained constant over the last 120 years, although the composition of the gluten has changed slightly. While the proportion of critically viewed gliadins fell by around 18 percent, the proportion of glutenins rose by around 25 percent. In addition, the researchers observed that higher precipitation in the year of the harvest was accompanied by a higher gluten content in the samples.
The bolding is mine—and it is surprising, considering there is some emerging consensus that these proteins are the proximate cause of both celiac and gluten sensitivity. The researchers concluded that environmental conditions such as how much rain there was had a “greater influence on protein composition than changes caused by breeding.”
Leaky Gut and Its Connection to Gluten Sensitivity
Increased intestinal permeability, or Leaky gut syndrome,, is a condition where the lining of the small intestine becomes damaged, allowing bacteria, toxins, and partially digested food particles (really larger molecules of food substrate than normal) to "leak" through the intestinal wall into the bloodstream. This can trigger inflammation through activation of the gut immune system and changes in the gut flora that may contribute to various health issues.
In the context of gluten sensitivity and celiac disease, a leaky gut could play a pivotal role. For some individuals, the reaction to gliadin may be exacerbated by an existing leaky gut, leading to more severe symptoms. The permeability of the gut lining allows more gliadin to enter the bloodstream, potentially increasing the immune response and symptom severity.
This highlights the interconnected nature of gastrointestinal health. For some individuals with gluten sensitivity, addressing gut health might be as important as avoiding gluten. For others, improving gut barrier function and reducing inflammation can be crucial steps in managing symptoms and improving overall well-being.
Gastroenterology vs. Integrative Medicine
Traditional gastroenterology tends to focus on diagnosing and treating specific gastrointestinal disorders like celiac disease through conventional methods, primarily diet modification and medication. This field often views gluten sensitivity with some skepticism due to the lack of diagnostic tests and the variable symptoms presented by patients.
From the aforementioned Science article: "Generally, the reaction of the gastroenterologist [was] to say, ‘You don't have celiac disease or wheat allergy. Goodbye,'" says Armin Alaedini, an immunologist at Columbia University. "A lot of people thought this is perhaps due to some other [food] sensitivity, or it's in people's heads."
Contrastingly, integrative medicine takes a holistic view of health, considering not just the physical symptoms but also the patient's emotional and mental well-being. It acknowledges the complexities of gluten-related disorders and explores a wider range of treatment options, including dietary changes, stress management, and alternative therapies. This approach is more open to considering conditions like non-celiac gluten sensitivity as legitimate and interconnected with other health issues like leaky gut syndrome.
Conclusion
As the science continues to evolve, one thing is clear: understanding celiac disease and gluten sensitivity requires a multifaceted approach.
Both functional medicine and integrative medicine allow for personalized treatment plans that address not only the dietary aspects but also the overall health of the individual, potentially leading to more effective and comprehensive management of symptoms.
If you are experiencing symptoms related to celiac disease or gluten sensitivity and would like to speak to an integrative medicine physician, contact us for a free 15-minute consultation.