Coeliac (or celiac) disease is a condition that affects the small bowel, caused by an abnormal immune response, or sensitivity, to a dietary protein known as gluten. Sensitivity to gluten causes inflammation and damage to the small intestine, and sometimes the damage is so severe that the intestine is unable to absorb essential nutrients, leading to diarrhoea, vitamin and mineral deficiencies and eventually malnutrition.
This condition affects up to 1 in 300 people in the United Kingdom, Europe and the USA. It is more common in some areas of the world, particularly on the west coast of Ireland, where 1 in every 100 people are thought to have coeliac disease. People of all ages can be affected, but symptoms only appear after gluten has been introduced into the diet. Sometimes a stressful event, such as an infection, injury, or surgery, will trigger symptoms of coeliac disease. One definite risk factor is a history of the condition in the family, as coeliac disease commonly occurs in people who are genetically prone to it. It has also been shown that people having another medical condition that is related to problems with the immune system, such as certain types of thyroid disease, type 1 diabetes, ulcerative colitis, lupus erythematosus, or rheumatoid arthritis, have an increased chance of developing coeliac disease.
SYMPTOMS
Coeliac disease has many and varied symptoms, and symptoms in adults are different to those in children. In childhood symptoms do not appear until gluten-containing foods (bread, cereal) are introduced into the diet.
Childhood symptoms;
- Poor appetite, irritability and a failure to gain weight.
- Vomiting and diarrhoea, which can lead to a wrong diagnosis of gastroenteritis.
- Swollen stomach.
- Arm and leg muscles may become wasted and thin.
Adult symptoms;
- Weight loss with pale, offensive diarrhoea.
- Constipation.
- Abdominal bloating with wind.
and occasionally:
- Extreme tiredness – which is a sign of anaemia.
- Psychological problems like depression.
- Bone pain and sometimes even fractures – which are due to thinning of the bones.
- Ulcers in the mouth.
- A blistering, itchy skin rash mostly on the elbows and knees, called dermatitis herpetiformis.
Some people with coeliac disease will also have conditions relating to the malabsorption of certain nutrients from the diet. A lack of vitamin D can cause osteomalacia — a condition resulting in soft, fragile bones, also known as rickets in children; and decreased calcium and vitamin D can cause osteoporosis — a loss of bone density that makes bones weak and more prone to fractures. A lack of iron, folic acid or vitamin B12 can cause anaemia.
COMPLICATIONS
Complications of coeliac disease are rare. They include the following:
- Infertility in women. Recurrent miscarriage is sometimes associated with coeliac disease.
- Severe anaemia in pregnancy because the bowel cannot absorb enough iron and vitamins to keep up with the demands of mother and baby.
- Intrauterine growth retardation. Babies who are small for their age in the womb are more frequently born to mothers with coeliac disease.
- Autoimmune diseases (thyroid disease, Type 1 diabetes and some types of liver disease such as primary biliary cirrhosis).
- Thinning of the bones (osteoporosis).
- A slightly increased risk of developing bowel cancer, intestinal lymphoma and cancer of the oesophagus.
A gluten-free diet reduces all these complications, as well as associated conditions such as dermatitis herpetiformis and mouth ulcers.
DIAGNOSIS
Your doctor may ask you about your bowel movements, whether you have lost weight or whether you have symptoms of anaemia (tiredness, exhaustion, pallor). He or she may also examine your abdomen, look for a blistering rash on your skin, or check for mouth ulcers. If your doctor suspects you have this condition, various blood tests will be requested.
Some of the blood tests detect antibodies that are often found in coeliac disease (i.e. anti-endomysial antibodies, anti-tissue transglutaminase antibodies and anti-gliadin antibodies). If high levels of those antibodies are present, you will probably need to have a biopsy taken of your small intestine to confirm the diagnosis. To obtain the biopsy, a doctor will perform an endoscopy - a test where an endoscope (a long, thin flexible tube with a camera on the end) is passed down your throat so that he or she can see inside your stomach and small intestine. A special instrument is passed through the endoscope to take tiny samples of your intestine, which are subsequently examined under a microscope. If you have coeliac disease, there will be evidence of damage to the lining of the small intestine.
Further blood tests to check for nutritional deficiencies may also be necessary. Your doctor may want to check whether you have a deficiency in iron, folic acid, calcium, vitamin B12, or vitamin D in your blood.
Your doctor may ask you about your bowel movements, whether you have lost weight or whether you have symptoms of anaemia (tiredness, exhaustion, pallor). He or she may also examine your abdomen, look for a blistering rash on your skin, or check for mouth ulcers. If your doctor suspects you have this condition, various blood tests will be requested.
Some of the blood tests detect antibodies that are often found in coeliac disease (i.e. anti-endomysial antibodies, anti-tissue transglutaminase antibodies and anti-gliadin antibodies). If high levels of those antibodies are present, you will probably need to have a biopsy taken of your small intestine to confirm the diagnosis. To obtain the biopsy, a doctor will perform an endoscopy - a test where an endoscope (a long, thin flexible tube with a camera on the end) is passed down your throat so that he or she can see inside your stomach and small intestine. A special instrument is passed through the endoscope to take tiny samples of your intestine, which are subsequently examined under a microscope. If you have coeliac disease, there will be evidence of damage to the lining of the small intestine.
Further blood tests to check for nutritional deficiencies may also be necessary. Your doctor may want to check whether you have a deficiency in iron, folic acid, calcium, vitamin B12, or vitamin D in your blood.
TREATMENT
There is no cure for coeliac disease, but it can be treated with a gluten-free diet. After diagnosis your GP should refer you for a consultation with a dietician or nutritionist, who can suggest healthy eating alternatives. Most people find that once gluten is excluded from their diet, their symptoms improve dramatically because the inflammation in the small intestine resolves, and any damage to its lining can heal. People with coeliac disease need to stick to this gluten-free diet for the rest of their lives to prevent further inflammation.
A small number of people who have severely damaged small intestines don’t improve straight away with a gluten-free diet. These people may need medications to help reduce the inflammation, such as corticosteroids. Some people may also need to be treated for nutritional deficiencies, usually with vitamin and mineral supplements (especially when pregnant or planning to get pregnant).
THE GLUTEN-FREE DIET
"Gluten" is a general term used for a particular type of protein (proline-rich protein, or prolamin) found in wheat. This protein gives dough made from wheat flour it's elasticity and plasticity, which gives it good baking properties. The various strains of wheat have varying gluten content, so different flours may have more or less gluten depending on which type of wheat they are derived from. For example, "strong" flour (used for bread) has higher gluten content than "soft" flour (used for cakes). In the context of coeliac disease, the term "gluten" is also loosely used to include similar proteins in rye, barley and oats. The prolamins in wheat (i.e. gliadin), rye (i.e. secalin), barley (i.e. hordein) and oats (i.e. avenin) are not identical, although they are closely related in structure.
If you wish to follow a gluten-free, diet you should consider the following:
There is no cure for coeliac disease, but it can be treated with a gluten-free diet. After diagnosis your GP should refer you for a consultation with a dietician or nutritionist, who can suggest healthy eating alternatives. Most people find that once gluten is excluded from their diet, their symptoms improve dramatically because the inflammation in the small intestine resolves, and any damage to its lining can heal. People with coeliac disease need to stick to this gluten-free diet for the rest of their lives to prevent further inflammation.
A small number of people who have severely damaged small intestines don’t improve straight away with a gluten-free diet. These people may need medications to help reduce the inflammation, such as corticosteroids. Some people may also need to be treated for nutritional deficiencies, usually with vitamin and mineral supplements (especially when pregnant or planning to get pregnant).
THE GLUTEN-FREE DIET
"Gluten" is a general term used for a particular type of protein (proline-rich protein, or prolamin) found in wheat. This protein gives dough made from wheat flour it's elasticity and plasticity, which gives it good baking properties. The various strains of wheat have varying gluten content, so different flours may have more or less gluten depending on which type of wheat they are derived from. For example, "strong" flour (used for bread) has higher gluten content than "soft" flour (used for cakes). In the context of coeliac disease, the term "gluten" is also loosely used to include similar proteins in rye, barley and oats. The prolamins in wheat (i.e. gliadin), rye (i.e. secalin), barley (i.e. hordein) and oats (i.e. avenin) are not identical, although they are closely related in structure.
If you wish to follow a gluten-free, diet you should consider the following:
- Become a member of the Coeliac Society and receive a copy of their list of gluten-free manufactured products. They also run regular meetings and information days.
- Also visit the website of the Irish Nutrition and Dietetic Institute. They provide lists of suitable restaurants in your area and travel cards to explain a gluten-free diet for when you go abroad.
- Check your medication and supplements are gluten-free before taking them.
- Gluten-free communion hosts must be ordered at your church if required.
- Be cautious with all processed foods and study the listed ingredients on food packet labels. Since November 2005, food labelling rules require pre-packed food, sold in the European Union, to show clearly on the label if it contains gluten. Look out for the following ingredients: cereal binder, wheat starch, modified wheat starch, wheat germ, malt, malt extract.
- Be aware that even 'safe' products might be changed by processing, cooking methods, embellishments and additives.
- Do not use breadcrumbs, or dust meat, fish or poultry with flour before cooking.
- Ordinary bread, cereals, crackers and pizza
- Noodles, spaghetti and various types of pasta
- Cakes, pastries and biscuits
- Liquorice, flour, and semolina
- Malt vinegar, soy sauce, mustard and mayonnaise
- Some tinned soups, sauces and gravies that are thickened with flour or starch
- Any food that is breaded, battered or stuffed
- Crisps and similar snacks, as well as chips in restaurants that could have hidden gluten
- Cooking oil (mixed vegetable oil), which may contain wheat-germ oil
- Beer (stout, lager, ale), whiskey and some alcopops
- Red meat, poultry, fish, eggs, and dairy products
- All fruit, salads, vegetables, potatoes
- Nuts
- Sunflower/olive oil, butter
- Gluten-free beer, cider, wine, spirits, sherry, port and champagne
- Rice, ground rice, rice flour, cornflour, maize flour, potato flour, soya flour, arrowroot, sago, tapioca, sweetcorn, maize, buckwheat, millet, commercial gluten free flours and breads which comply with the International Standard for gluten-free food (Codex Alimentarius)
- Store your food separately
- Do not share a toaster
- Have your own breadboard or chopping board
- Use your own butter and spreads including jams and marmalades
- Cook your food in fresh oil if using a deep fat fryer
- Inform restaurant managers or chefs that you are a Coeliac if eating out - this will prevent cross contamination of your meal in their kitchen
USEFUL CONTACTS
Coeliac Society of Ireland
Carmichael House, 4 North Brunswick Street, Dublin 7
www.coeliac.ie
Tel: 00353-1-8721471
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Irish Nutrition and Dietetic Institute
Ashgrove House, Kill Avenue, Dun Laoghaire, Co. Dublin
www.indi.iee
Tel: 00353-1-2804839
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