- Area: Health Sciences
- Program: Health Sciences
- Type of Writing: Report
- Course Level: 1000
- English Speaking Nativeness: Native
- Year: 2017
- Paper ID: HS.H.S.R.1.N.2.7
Celiac disease is a nutrition-related, heritable autoimmune disorder affecting approximately 1% of the population in the United States. This research paper describes the disease, its causes, symptoms, health complications, and treatment, as well as the role of diet and activity in managing the disease.
Keywords: celiac disease, gluten, autoimmune disorders
An examination of my family history did not reveal evidence of a familial chronic disease related to nutrition. I selected celiac disease as my topic because a close friend’s daughter, Elizabeth, was diagnosed several years ago. Celiac disease is directly related to both genes and diet, has nutritional implications, and currently can be effectively managed only through permanent dietary changes.
A predisposition for celiac disease runs in Elizabeth’s paternal line, however, my friend was not aware of other cases in the family when her daughter’s symptoms began. Because no family history of the condition was reported at intake, doctors did not initially suspect celiac disease as the cause of Elizabeth’s problems. The path to a diagnosis was long and circuitous. This is not unusual. Although celiac disease is not rare, some of the symptoms seem unrelated to the digestive system, and several are also associated with other conditions. The diversity and nonspecificity of symptoms can lead to a delay in accurate diagnosis.
Description of the Disease
Celiac disease is an autoimmune disorder in which the immune system produces antibodies to certain protein complexes found in wheat, barley, and rye and attacks the mucosa of the small intestine when these proteins are consumed (Bower, Sharrett & Plogsted, 2014).
Accumulated damage to the villi of the small intestine inhibits the absorption of important nutrients into the bloodstream. The disease has serious implications and can affect multiple body systems (Mayo Foundation for Medical Education & Research, 2015). An alternate form of celiac disease is dermatitis herpetiformis, which manifests as an itchy, blistering skin rash and may or may not include the typical digestive symptoms. Celiac disease is more prevalent than many realize, affecting approximately 1% of Americans, or nearly 3 million people. The age of onset varies widely (The University of Chicago Celiac Disease Center [UCCDC], n.d.).
Caucasians and females have a higher rate of diagnosis (NIDDK, n.d.). Non-celiac gluten sensitivity and wheat allergy share some gastrointestinal symptoms but are distinct and, notably, do not cause the destruction of the intestinal villi that is seen in celiac disease (Bower, Sharrett & Plogsted, 2014).
In children under 2 years of age, symptoms of celiac disease may include vomiting, chronic diarrhea, a distended belly, poor appetite, failure to thrive, and muscle wasting. Older children may have symptoms such as diarrhea or constipation, weight loss, short stature, delayed puberty, or neurological problems. Common symptoms for adults are diarrhea, fatigue, weight loss, bloating and gas, abdominal pain, nausea, constipation, and vomiting. Difficulties in diagnosing celiac disease arise when symptoms occur which may seem unconnected to digestion, such as anemia, osteoporosis or osteomalacia, skin rash, damage to dental enamel, mouth ulcers, headaches, peripheral numbness and tingling, and joint pain (Mayo Clinic, n.d.). Helms (2005) noted that undiagnosed celiac disease sufferers “often spend years seeking help for complaints such as ataxia, arthritis, epilepsy, depression, neuropathy, and a host of other conditions seemingly unrelated to digestion” (p. 186). There are more than 200 signs and symptoms of celiac disease. Yet many individuals have no symptoms at all and remain undiagnosed and at risk for complications. When celiac disease is suspected, antibody tests and an endoscopic biopsy are the most common means of confirming the diagnosis (UCCDC, n.d.).
Evidence suggests that celiac disease is not a new phenomenon and has plagued humankind for centuries. The birth of agricultural practices 10,000 years ago greatly increased the consumption of grains and is a likely point of origin for celiac disease and other allergies. According to Fasano (2009, “Early Insights,” para. 1), celiac disease “acquired a name in the first century A.D., when Aretaeus of Cappadocia, a Greek physician, reported the first scientific description, calling it koiliakos, after the Greek word for ‘abdomen,’ koelia.” Since at least the 19th century, physicians have experimented with dietary changes as a way to alleviate the symptoms now attributed to celiac disease. The link to wheat proteins was finally established in the 1950s. Subsequent research has led to a better understanding of the disease and improved diagnostic procedures (Bower, Sharrett & Plogsted, 2014).
A predisposition to celiac disease is an inherited condition. Bower (2014, “Preface,” para. 2) stated that the incidence of celiac disease in families “is 1 in 22 for first-degree relatives (parents and siblings) and 1 in 39 in second-degree relatives (grandparents, aunts, uncles, and cousins).” The genes identified as HLA-DQ2 and HLA-DQ8 are present in 98% of people with celiac disease. People are not born with the disease, but it can develop in those individuals who have inherited the genes. The precise cause of disease onset is unknown, although an environmental trigger is suspected; possibilities include pregnancy and stress (Bower, Sharrett & Plogsted, 2014). A recent study suggests a possible link to reovirus T1L, a virus that is common and usually harmless (Eaton, 2017). According to Helms (2005), “the pathogenesis of CD probably involves a sequence of interrelated events” (p. 179).
Celiac disease can affect multiple body systems, with a variety of complications. One of the most serious complications is cancer. Chronic inflammation of the lining of the small intestine may be responsible for an increased risk of non-Hodgkin’s lymphoma, esophageal cancer, and adenocarcinoma of the small intestine. Malnutrition and malabsorption are also a common concern. Damage to the villi of the small intestine and its subsequent failure to absorb nutrients such as iron and calcium can lead to anemia, problems related to bone density, and defects in dental enamel. Rickets may occur in children due to deficiencies in calcium and vitamin D (Bower, Sharrett & Plogsted, 2014). Malnutrition can lead to weight loss, growth problems, and delayed puberty. Infertility and miscarriage may also occur (Mayo Clinic, n.d.). The University of Chicago Celiac Disease Center (n.d.) noted that “deficiencies in B12, copper, folate, magnesium, niacin, riboflavin, and/or zinc” have been observed in individuals with celiac disease. Other known or suspected complications include lactose intolerance, permeable gut, cholestatic liver disease, and other liver disorders (Bower, Sharrett & Plogsted, 2014).
Tissue transglutaminase antibody, commonly found in people with celiac disease, is present in the skin and brain as well as the gastrointestinal system, which may account for an association with several neurologic symptoms including balance issues, depression, anxiety, neuropathy, seizures, attention deficit disorder, headaches, and learning disorders (Bower, Sharrett & Plogsted, 2014).
Medical conditions frequently associated with celiac disease include epilepsy, Addison’s disease, type 1 diabetes mellitus, thyroiditis, rheumatoid arthritis, and Sjogren’s syndrome (Helms, 2005, p. 181-182). Type 1 diabetes mellitus and celiac disease have been found to coexist in as many as 1 in 6 cases. The financial and psychological burden of managing dietary restrictions for both diseases can be challenging (Vyas & Jain, 2016, p. 4-5).
Despite recent advances, much remains to be learned about celiac disease. Because the precise cause is unknown, no vaccine or other means of prevention is currently available. At-risk individuals, such as those with affected family members, may wish to have DNA testing to determine whether or not they have the genes responsible for the development of celiac disease. People without the genes cannot develop the disease; those with the genes are at risk of developing the disease at some point and may choose to be monitored with antibody testing (UCCDC, n.d.). Early diagnosis is important to prevent complications. The sooner a gluten-free diet is established, the better, as it may take longer for the intestinal villi of older patients to heal (Bower, Sharrett & Plogsted, 2014).
There is no cure for celiac disease. Although research is ongoing, a strict, gluten-free diet is currently the only effective treatment, and must be maintained for life. Harmful forms of gluten are found in a wide variety of grains and grain products such as wheat, barley, rye, couscous, durum, einkorn, farro, graham, malt, matzo, orzo, semolina, spelt, triticale, udon, and some oats (Bower, Sharrett & Plogsted, 2014). Other, less obvious sources of gluten may be present in products such as food starches, preservatives and stabilizers, medications and supplements, lipsticks, toothpaste, and mouthwash. Even something as innocuous as Play-Doh may be a source of gluten. Permanently removing all sources of gluten from the diet allows for eventual healing of the small intestine. Upon diagnosis of celiac disease, supplements may be prescribed to address any existing nutritional deficiencies. Steroids are sometimes used in the short term to bring inflammation under control. Dapsone, a skin medication, may be used in conjunction with a gluten-free diet to treat dermatitis herpetiformis (Mayo Clinic, n.d.).
Extent of Diet’s Role
Diet plays a central and critical role in the management of celiac disease and the prevention of complications from nutrient malabsorption. The primary key to staying healthy is avoiding gluten. The majority of people with celiac disease will notice an improvement soon after starting a gluten-free diet. Damage to the small intestine will gradually heal and nutrients will once again be properly absorbed. The healing process is often faster in children than adults (NIDDK, n.d.).
A person with celiac disease must be vigilant and avoid any products that contain gluten. This means all products that contain wheat, barley, and rye in any form. Oats do not contain gluten, but are often contaminated during processing. Most cereals, grains, and pasta contain gluten, as do many processed foods, additives, and seasonings. Many gluten-free substitutes for these products are available. A variety of fresh foods are naturally free of gluten and can be safely consumed, including meat, poultry, fish, milk, cheese, eggs, fruits, vegetables, potatoes, rice, beans, seeds, and nuts (Mayo Foundation for Medical Education & Research, 2015).
Individuals with celiac disease must make a practice of carefully reading all food labels and exercising care when eating at restaurants or social gatherings. Wheat, barley, and rye can be hidden ingredients: “wheat and its derivatives are used to thicken sauces and condiments, as flavoring agents in dairy products and many other processed foods, and in breading for deep-fried vegetables and meats” (Wardlaw, Smith, & Collene, 2014, p. 113).
Designing a healthy gluten-free diet requires extra attention in order to address any existing vitamin and mineral deficiencies and prevent new ones from developing. Many gluten-free grain products are not enriched or fortified, and can be low in B vitamins and iron.
Substitute starches may lack fiber and nutrients. Avoiding milk products due to the lactose intolerance that is common with celiac disease may result in deficiencies in calcium and vitamin D. In addition, gluten-free products often contain more fat and sugar than traditional foods (Bower, Sharrett & Plogsted, 2014). Consulting a dietician, support group, or gluten-free cookbook can be helpful to ensure a varied and healthful diet.
Effects of Activity and Exercise
While activity and exercise have no direct therapeutic role in celiac disease management, their contribution to general health and well-being should not be overlooked. The 2008 Physical Activity Guidelines for Americans recommends that adults should participate in 150 or more minutes per week of moderate-intensity aerobic physical activity and should also engage in muscle-strengthening activities. For children and adolescents, 60 minutes of more of physical activity daily is recommended (Wardlaw, Smith, & Collene, 2014, p. 48). As an added benefit, regular physical exercise may help affected individuals with the weight management challenges common to celiac disease. Gluten-free products are often higher in fat and calories. Bower (2014) notes that “switching to gluten-free foods can result in weight gain, especially in the first few years” (p. 114).
Elizabeth has followed a strict gluten-free diet since her diagnosis 9 years ago at the age of 7. Fortunately, her endoscopic biopsy at that time revealed minimal damage to the villi. My friend reported that Elizabeth experienced significant improvement in symptoms within a week of starting the gluten-free diet. Elizabeth has always taken her condition and the diet in stride. She is now a healthy, active teen. She packs her own lunches and snacks to take to school and events away from home. She is careful to read labels and ask pertinent questions when she buys products and eats at restaurants and social gatherings. To prevent accidental exposure and protect Elizabeth’s health, the family maintains a “safe-zone” in the kitchen for the storage and preparation of gluten-free foods. For convenience sake, the entire family primarily eats fresh foods that are naturally gluten free. The biggest challenges are higher expenditures of both money and time. Every year, Elizabeth is tested for antibodies and for type 1 diabetes. There is every reason to believe that with continued adherence to the gluten-free diet, she has a healthy future ahead.
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Eaton, E. S. (2017). Virus may trigger celiac disease. Science News, 191(8), 7. Retrieved from https://www.sciencenews.org/
Fasano, A. (2009). Surprises from Celiac Disease. Scientific American, 301(2), 54-61. doi:10.1038/scientificamerican0809-54
Helms, S. (2005). Celiac disease and gluten-associated diseases. Alternative Medicine Review: A Journal Of Clinical Therapeutics, 10(3), 172-192. Retrieved from http://www.altmedrev.com/publications/10/3/172.pdf
Mayo Clinic. (n.d.). Celiac disease. Retrieved from http://www.mayoclinic.org/diseases-conditions/celiac-disease/home/ovc-20214625
Mayo Foundation for Medical Education & Research. (2015). Celiac disease. Mayo Clinic Health Letter, 33,1-8. Retrieved from http://healthletter.mayoclinic.com/
NIDDK. (n.d.). Celiac disease. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease
The University of Chicago Celiac Disease Center. (n.d.). Education. Retrieved from http://www.cureceliacdisease.org
Vyas, V., & Jain, V. (2017). Celiac disease & type 1 diabetes mellitus: Connections & implications. The Indian Journal Of Medical Research, 145(1), 4-6. doi:10.4103/ijmr.IJMR_1223_16
Wardlaw, G. M., Smith, A. M., & Collene, A. (2014). Contemporary nutrition: a functional approach (4th ed.). New York, NY: McGraw-Hill Education.
Keywords: gluten, autoimmune disorder, genetic condition