Celiac disease and your questions

What is celiac disease?

Per Pavelka , MD, Internal Medicine and Gastroenterology

Celiac disease is a permanent intolerance to gluten in food. Celiac disease is a genetic, maladaptive reaction of the body to gluten (gluten) that results in damage to the epithelial cells of the intestine. Because of this handicap, nutrients can be difficult to absorb. Gluten is found in wheat, rye, barley and oats. When gluten is removed from the diet, the lining of the intestine regenerates relatively quickly and symptoms lessen or disappear. It is an autoimmune lifelong disease. The trigger is gluten, and a close genetic link with the development of a specific autoimmune reaction (AtTGA) is assumed.

What are the forms of celiac disease?

1. The classical form - the best known, in which all clinical symptoms and atrophic changes in the mucosa are present. Typical symptoms are diarrhea, abdominal pain, weight loss, and appetite.

2.Atypical form - symptoms outside the digestive system, e.g. growth restriction, anaemia, dental enamel defects, emotional disturbances.

3. Dumb form - when there are no obvious symptoms of the disease, only after diagnosis does the suspicion of celiac disease become apparent. In this group there are often relatives of celiac disease patients in whom antibodies are found in the family history. Such patients only notice an improvement in their mental condition, disappearance of flatulence and feel better after the introduction of a gluten-free diet.

4.The concealed form - in patients with genetic predispositions for the occurrence of the disease, in whom we do not detect changes during the investigation, but in whom clinical symptoms and changes in the mucosa of the small intestine have occurred in the past or will occur in the future. In such persons, we detect the presence of serological markers of celiac disease.

5. Potential - genetic predisposition for the disease.4. The classical form of the disease occurs in Europe with an average frequency of 1:200 - 1:250. Clinical symptoms can appear at any age, after varying lengths of exposure to gluten. The onset of symptoms may be delayed if the child has been breastfed for a long time; early introduction of gluten into the diet may accelerate the disease process. Currently, celiac disease is most commonly diagnosed in school-age and preschool children. A rotavirus infection or another disease, such as diabetes, may be a factor in the onset of symptoms. Diagnosis of the disease may be based on clinical symptoms, blood tests - serological markers of celiac disease and biopsy of the lining of the small intestine.

Celiac disease in questions:

What is gluten (gluten)?

• Gluten is a protein present in certain cereals such as wheat, oats, barley, rye, spelt, kamut, and triticale. The nutritional value of gluten is very low. The main function of this protein is that it acts as a "binder", holding together the cereal flour so that it can be made into bread.

Celiac disease is hereditary?

• Celiac disease is 10 times more common in relatives compared to the rest of the general population. Why this is so is not yet fully understood. In contrast, the environmental contribution to the incidence of the disease can be determined from the presence of gluten in the diet. Coeliac disease is a complex pathology, caused by a "mosaic" of hereditary and environmental factors.

How does celiac disease manifest itself?

• The most striking symptoms are diarrhoea, weight loss and loss of strength, bloating and abdominal pain, vomiting and, in children, stunted growth. Other times, symptoms seemingly unrelated to the digestive system, such as anaemia, osteoporosis, missed periods, vitamin and mineral salt deficiencies, or other associated pathologies. However, coeliac disease is often not manifested in a clear-cut manner, and its various manifestations must be taken into account when making a diagnosis. The various clinical manifestations of celiac disease can be divided into typical cases, in which clear signs of digestive disorders can be observed (but these are now fewer in number). However, atypical cases, characterised by vague manifestations such as irritable bowel, are more common. Another common symptom is iron deficiency.

Diabetes and celiac disease?

• 5-10% of patients with type I diabetes (insulin dependent) also have celiac disease. To treat these two disorders, strict adherence to a diet is essential, but not totally restrictive. In fact, today, diabetics with and without associated coeliac disease are advised to eat a normal diet in terms of total calories and protein, sugars and fats. In order to avoid an excessive rise in glycaemia after a meal, it is recommended to consume complex carbohydrates (bread, pasta, gluten-free of course) and foods rich in fibre (vegetables, legumes and fresh fruit). Foods containing simple sugars (sweets) can be eaten, but in moderation. As regards fats, it is better to choose vegetable fats (e.g. virgin olive oil) and fats rich in unsaturated acids (e.g. some marine fish), as they have a beneficial effect on blood cholesterol levels. Finally, it should be noted that the treatment of celiac disease also has a beneficial effect on the treatment of diabetes, as it helps to better control metabolism and possibly reduce the need for insulin; it also helps to prevent possible 'silent' complications such as anaemia and osteoporosis.

How does lactose intolerance develop?

• An individual affected by celiac disease mayhave lactose intolerance, caused by extensive damage to the intestinal mucosa ,even before diagnosis. However, lactose intolerance may persist to some extent even after treatment for celiac disease has been initiated, even if the intestinal mucosa has sufficiently recovered. This may be due to a genetic enzyme deficiency, which is quite common in the population mainly in southern Europe and has nothing to do with celiac disease per se. In these cases, consuming mainly whole milk can cause symptoms such as abdominal pain and flatulence. This disorder is treated by removing lactose-rich foods such as whole milk and creamy ice creams from the diet. It is recommended to replace whole milk with low lactose milk. As the intestines retain the ability to digest small amounts of lactose, there is usually no problem with other dairy products such as yoghurt and cheese and milk biscuits in normal cases. However, people who are very sensitive to lactose must give up all dairy products.It appears in association with celiac disease,but has other causes.

What are the positive effects of a gluten-free diet?

• When the diet is started, clinical symptoms disappear, antibody testing has normal results, and the intestinal mucosa stabilizes to a normal state. In a person with typical symptoms, the effects of the therapy are miraculous: in a few days, appetite and general mood improve, diarrhoea gradually disappears and, in children, natural growth returns. Even possible metabolic disorders, such as a lack of mineral salts in the bones or iron deficiency with subsequent anaemia, are slowly corrected. Early treatment with diet primarily reduces the risk of long-term complications, but does not 'cancel out' all the possible immune system pathologies that are sometimes associated. These include, for example, thyroid dysfunction.

What safety rules should be observed in the kitchen?

• Choose ingredients that are definitely gluten-free. Avoid contact with food with soiled hands or unwashed utensils and dishes (bowls, cooking pots, pasta drains, pots, etc.) that have been in contact with prohibited foods. Do not place food directly on contaminated surfaces such as the work surface of the kitchen counter, baking trays, the bottom of the oven, the surface of the stove or the griddle. Always clean them before starting work. Do not use frying oil that has previously been used for food containing gluten. Do not use cooking water that has already been used to cook pasta with gluten. Use baking paper or foil on hobs or surfaces that may be contaminated.

How to prepare a dish that is sure to be gluten-free?

• Celiac disease is not a disease, it is a way of life. After all, even after starting treatment, the psychosomatic state of health improves noticeably, but it is necessary to learn to live with the rules associated with the new dietary regime. The large selection of gluten-free products currently marketed by specialist food companies has contributed greatly to improving the quality of life of people with coeliac disease. Gluten-free foods are becoming more readily available. The burden of dietary restrictions is felt when eating out, as gluten-free meals or snacks are still quite scarce in catering establishments (canteens, cafeterias, restaurants). Even so, it can be said that the situation is improving year on year, as the patients' associations have been trying to do.

Coeliac disease and school

• Some schools are able to provide meals for children with coeliac disease. However, it is essential that the child's parents check that the teachers and kitchen staff are aware of the problem. The existing selection of gluten-free products allows events such as school trips and birthday parties to go ahead without problems.

Coeliac disease and growing up?

• Dietary violations tend to occur during adolescence, as many young people find it difficult to accept, and especially to express to others, their 'dietary difference'. The frequent absence of symptoms may reinforce the tendency to random dietary violations. What to do in such cases? The right thing to do is to avoid blaming or, even worse, intimidation; it is better to focus on correct information and attitudes that help to improve compliance with the diet. In selected cases, especially when there are conflicts between young patients and their parents, it is possible to use the help of a psychologist. Difficulties in adolescence are usually transient and do not preclude the possibility of achieving the goal of accepting life with celiac disease over time.