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Gluten -Related Disorders

Does gluten sensitivity exist? And if it does, what is the difference between celiac disease and gluten sensitivity?

Thu 07 Dec 2023 | 08:17 AM
Dr Magdy Badran , Consultant Ped Social Anxiety
Dr Magdy Badran , Consultant Ped Social Anxiety
Dr. Magdy Badran

Gluten is one of the most controversial and misunderstood food compounds. Gluten is naturally occurring, but it can be extracted, concentrated, and added to food and other products to add protein, texture, and flavor. It also works as a binding agent to hold processed foods together and give them shape.

Gluten encompasses a number of proteins called prolamins. Prolamins are present in wheat, rye, barley, and a cross between wheat and rye known as triticale. Although there are many prolamins present in these grains, gliadin and glutenin are the main prolamins in wheat.

Protease is the enzyme that helps our body process proteins, but it can’t completely break down gluten. Undigested gluten makes its way to the small intestine. Most people can handle the undigested gluten with no problems. But in some people, gluten can trigger a severe autoimmune response or other unpleasant symptoms.

Some people could have small intestines that don’t work properly. The lining might be too permeable, allowing some undigested gluten, bacteria, or other substances to go through the lining and into the bloodstream, causing inflammation in susceptible individuals.

Gluten proteins are exceptionally resistant to digestion in all people, not just in people who have celiac disease, which is an autoimmune condition.

Celiac Disease

Celiac disease is the most well-known gluten-related medical condition. It is an autoimmune disease that involves the immune system reacting to gluten proteins.

Celiac disease is a genetic autoimmune condition that mainly affects the gastrointestinal tract when gluten is ingested. When someone with Celiac disease eats gluten, the lining of the small intestine becomes damaged and is unable to absorb nutrients properly.

Currently the only treatment for Celiac disease is the lifelong adherence to a strict gluten-free diet. All food that either contains gluten or might have had contact with gluten (known as cross-contact) must be avoided.

People with Celiac disease must watch for cross-contact and/or items that have been used with gluten containing food and cannot be sufficiently cleaned. For example: toasters, toaster ovens, air fryers, food preparation surfaces, condiments and spreads, shared serving utensils, colanders/strainers, and deep fryers.

Celiac disease is common, affecting at least 1% of the population. Upwards of 83% of people with Celiac disease are undiagnosed. When a first-degree family member has Celiac disease, the probability of developing it increases significantly. Celiac disease can develop at any age. Celiac disease affects individuals of all ethnicities

There are over 200 symptoms of Celiac disease, and they vary so widely that there is no such thing as a typical case. Many people do not experience any of the gastric symptoms that were previously thought to typify the condition. These individuals often face a delay in diagnosis. Physical symptoms may include abdominal cramping, amenorrhea, anemia, bloating/distention, brain fog/inability to concentrate, canker sores, constipation, dental abnormalities, diarrhea, edema/swelling, electrolyte imbalance, elevated liver enzymes, fatigue, headaches, infertility/miscarriage, osteopenia/ osteoporosis, pain in bones and joints, peripheral neuropathy, rash, stool abnormalities, vitamin and mineral deficiencies, vomiting, and weight loss or gain.

Emotional symptoms of Celiac disease may include anxiety, depression, irritability, and mood changes.

Children with Celiac disease may exhibit any of the previously listed symptoms as well as failure to thrive, delayed puberty, and ADHD-like symptoms.

Wheat Allergy

People with a wheat allergy have an allergic reaction to proteins present in wheat. Studies suggest that between 0.2% and 1.3% of the world population has a wheat allergy.

Proteins in wheat cause your immune system to overreact. Wheat protein types that you may be allergic to are albumin, gliadin, globulin, and gluten. You're at increased risk of allergy to wheat or other foods if your parents have food allergies or other allergies, such as asthma.

Wheat allergy is most common in babies and toddlers, who have immature immune and digestive systems. Most children outgrow wheat allergy by 16, but adults can develop it, often as a cross-sensitivity to grass pollen.

Generally, you are at greater risk for developing an allergy to any food, including wheat, if you come from a family in which allergies or allergic diseases, such as asthma or eczema, are common. If both of your parents have allergies, you’re more likely to develop a food allergy than someone with only one parent who has allergies.

Wheat allergy can produce severe symptoms, including anaphylaxis, which is an allergic reaction that can be life threatening. Although both celiac disease and wheat allergy are serious conditions, the mechanisms involved in either of them differ. For example, unlike celiac disease, wheat allergy can be immunoglobulin E (IgE) mediated. This means that wheat specific IgE antibodies bind to wheat, thereby triggering the release of inflammatory compounds, including histamine.

IgE-mediated immune responses are immediate and can be life threatening. A response can also stem from wheat inhalation — for instance, when baking with wheat flour.

Non-IgE reactions involve your immune system, but not your IgE antibodies. Your allergic reaction to wheat is slower than an IgE-mediated reaction. It may take up to 48 hours to develop.

Wheat-dependent, Exercise-induced Anaphylaxis

Some people with wheat allergy develop symptoms only if they exercise within a few hours after eating wheat. Exercise-induced changes in your body either trigger an allergic reaction or worsen an immune system response to a wheat protein. This condition usually results in life-threatening anaphylaxis.

Non-celiac Gluten Sensitivity

Some people experience reactions to gluten even though they do not have celiac disease or an allergy to wheat. Non-celiac gluten sensitivity (gluten intolerance) (NCGS) is gastrointestinal irritation caused by gluten in people who don’t have celiac disease. NCGS is much more common than celiac disease and may impact up to 13% of the population.

Like celiac disease, NCGS is more common in females. People with NCGS experience gastrointestinal symptoms that include bloating, gas, and diarrhea, as well as non- gastrointestinal symptoms, such as fatigue, anxiety, and headaches. These symptoms often improve on a gluten-free diet.

If a person experiences the symptoms listed above after consuming gluten, a doctor must rule out celiac disease and wheat allergy before they can diagnose NCGS. There are currently no tests that can help diagnose NCGS, which is why the condition remains a diagnosis of exclusion.

Gluten Ataxia

Gluten ataxia is a rare neurological autoimmune disorder that causes the body to attack parts of the brain in response to gluten.

Dermatitis Herpetiformis

The name herpetiformis is derived from the tendency for blisters to appear in clusters, resembling herpes simplex. Dermatitis Herpetiformis is an uncommon cutaneous eruption associated with gluten sensitivity characterized by intensely pruritic, inflammatory papules and vesicles on the forearm, knees, or buttocks.

Dermatitis herpetiformis has a prevalence of 10 per 100,000 population. There is a male predominance of 2:1. Some patients have a personal or family history of other autoimmune diseases including thyroid disease, pernicious anemia, type 1 diabetes, vitiligo, Addison disease, alopecia areata, and haemochromatosis.