“There is a kind of chronic indigestion which is met with in persons of all ages, yet is especially apt to affect children between one and five years old. Signs of the disease are yielded by the faeces; being loose, not formed, but not watery; more bulky than the food taken would seem to account for; pale in colour, as if devoid of bile; yeasty, frothy, an appearance probably due to fermentation; stinking, stench often very great, the food having undergone putrefaction rather than concoction…but if the patient can be cured at all, it must be by means of diet.” –Dr Samuel Gee 1888
$2.5 billion USD was spent in 2010 on gluten free products. This spending makes big business, government and the media sit up and take notice.
Gluten is the main structural protein in wheat (with equivalent toxic proteins found in rye and barley) These toxic protein fractions of gluten include gliadins and glutenins.
With NY Bestsellers like Wheat Belly and Grain Brain, the experts may still be deliberating, but the patients are voting with their purchases and eating choices.
Gluten sensitivity is now estimated to be affecting not 3% but up to 30% of the population!
Gluten free eating is expensive and difficult. But when you experience a life with the symptoms of gluten sensitivity, and the subsequent ‘recovery’ and wonderful effects of removing this toxin – there is no need for any expert to confirm what is a very clear and real improvement to health and quality of life.
The difficulty is proving the positive changes are significant and not due to the very powerful placebo effect. The concern is placing unnecessary restrictions and increased financial strain on families if there is no real medical need.
Let’s look at diagnosis and categories. There are three main types of Gluten disorders:
- Allergic – Wheat allergy – this is like a typical bee sting or peanut allergy. It occurs minutes to hours after exposure. This is the least common and can lead to severe illness and death. Classic food allergy affecting the skin, gastrointestinal tract or respiratory tract. (This category includes Occupational Asthma (Bakers asthma), rhinitis and contact urticaria.) IgE antibodies play a central role in the pathogenesis of these diseases. Skin prick testing is less effective due to cross-reactivity with grass pollens (PPV less than 75%) So blood testing is the suggested – IgE antibodies (anti-wheat, rye barley and anti-alpha-amylase igE in serum)
- Autoimmune – True Coeliac disease, includes dermatitis heretiformic, and gluten ataxia. First described in ancient Greece where Aretaeus named it “koiliakos’ meaning ‘suffering in the bowels’. 17 Centuries later “Some patients have appeared to derive considerable advantage from living almost entirely upon rice..” Dr Matthew Baillie 1800’s
Blood measurement of IgA antibodies to transglutaminase (anti-tTG) is recommended for initial testing for Coeliac Disease while IgA anti-endomysial antibodies is considered as a confirmatory test. Histological findings of a small bowel biopsy remain the gold standard of diagnosis for Coeliac Disease.
Dr Stephano Guandialini in 1980’s refined the diagnosis, now The Marsh Classification recognises increased intraepithelial lymphocytes and crypt hyperplasia with intact villi as part of gluten enteropathy spectrum while some individuals have more subtle abnormalities identified only on electron microscopy. The histological diagnosis of Coeliac Disease no longer requires small intestine villous atrophy.
During the 1970s, Coeliac Disease was considered a rare disorder affecting 1:1000 (0.1%) individuals predominantly of European origin. We now know that Coeliac Disease occurs in both adults and children at rates approaching 1% of the population, and is recognised not only throughout Europe and in countries populated by persons of European ancestry, but also in North and South America, Australia, New Zealand, South-West Asia and North Africa. 75% of individuals with Coeliac Disease remain undiagnosed. The rate of diagnosis is increasing. A negative test result for serology or small bowel histopathology does not preclude Coeliac Disease development at a later stage.
Is Genotyping – Gene Testing useful to predict future development? 99% of patients with Coeliac Disease carry one or both the genes. HLA DQ2 or DQ8 halotypes have an excellent negative predictive value – so these are good for a ‘once and for all’ exclusion test. If you don’t have any you can be reassured.
Gluten challenge: How much?
For patients with positive gene tests ( HLA DQ2 or DQ8 halotypes), who wish to proceed with a formal diagnostic process, a gluten challenge is required. Four slices of bread for an adult and two or more slices of bread for a child consumed for six weeks is considered enough to produce the serological and histological evidence required for a diagnosis of Coeliac Disease.
- Possible Immune Mediated – Gluten Sensitivity
Though due to the steady modification of wheat, and pre-treatment of flours.
Some individuals who experience distress when eating gluten-containing products and show improvement when eating gluten-free may have Gluten Sensitivity instead of Coeliac Disease. Gluten Sensitivity is a condition distinct from Coeliac Disease and is not accompanied by the concurrence of anti-tTG autoantibodies or other autoimmune comorbidities.
There are no serology or genetic tests to confirm gluten sensitivity. This is a clinical diagnosis, with a symptomatic patient doing an elimination test then reintroduction to prove the symptoms.
There is life threatening immediate wheat allergy – IgE blood tests can detect.
Coeliac Disease is a genetically predetermined, but environmentally triggered autoimmune disease diagnosed by Blood anti –TTG and confirmed with Anti-endomysial Ab’s. This is then confirmed with a biopsy of the bowel during gastroscopy. This can be false if not exposed to gluten at the time if symptoms continue exposure and retest are necessary. Gene testing can rule out, but is not very accurate at ruling in Coeliac. 1% of the population or 200,000 Australians are Coeliac, but 75% of Coeliacs are undiagnosed.
Gluten sensitivity is on the rise, maybe due to changes in wheat and flour treatment. There is no testing it is a clinical diagnosis. Elimination of all wheat rye barley and oats, and processed gluten-containing products is the treatment.
- Dr Joanna Harnett PhD
- Dr Matthew Baille 1888
- Ludvigsson, Brandt et al. 2009
- Walker and Murray 2011
- Lohi, Mustalahti et al. 2007
- Accomando and Cataldo 2004; Lohi, Mustalahti et al. 2007; Lohi 2010
- West, Logan et al.2003
- Anderson.2008.Tye-Din and Anderson 2008; Kneepkens and von Blomberg
- Gibson, Shepherd et al.2012.
- ACNEM (Australian College of Nutritional and Environmental Medicine)
- Gastrointestinal Disorders Protocol.