Articles
The Emerging Definition of Gluten Sensitivity
An overview of the recent international Celiac Disease Symposium discussions on Gluten Sensitivity
There is increasing attention being paid to those who are not celiac but respond to the gluten free diet. Awareness of gluten as an underlying contributor to many chronic diseases has been growing internationally. This led to the recent definition of the term gluten sensitivity at the 11th International Celiac Disease Symposium in Oslo, Norway in June 2011. Gluten sensitivity can be indistinguishable from celiac disease or wheat allergy based on symptoms alone. It has been the catch all for people who feel better gluten free but whose labs don’t fit them into the first two categories
It is becoming clear that gluten issues are on the rise with celiac doubling every fifteen years. (Catassi et al., 2010). Gluten sensitivity is estimated to be 6 times more prevalent than celiac disease, which affects one in one hundred thirty-two (Jackson, Eaton, Cascella, Fasano, & Kelly, 2011). According to the University of Maryland Center for Celiac Research (CFCR), who have been driving much of the research to validate gluten sensitivity as a separate entity, the following list breaks down common symptoms of gluten sensitivity:
o Abdominal pain 68%
o Eczema and/or rash 40%
o Headache: 35%
o “Foggy mind” 34%
o Fatigue: 33%
o Diarrhea: 33%
o Depression: 22%
o Anemia: 20%
o Numbness in legs/arms/fingers: 20%
o Joint pain 11%
The new working definition of gluten sensitivity presented in Oslo is essentially a diagnosis of exclusion. That said positive anti-gliaden antibodies are considered part of the diagnosis. According to Dr. Fasano’s presentation in Oslo, gluten sensitivity is not genetic, there is little to no intestinal damage (no more than Marsh 1), celiac blood tests (EMA or tTG IgA) are negative and wheat allergy tests are negative. Other things that may cause similar symptoms that also need to be ruled out are disorders of digestion and absorption, inborn errors of metabolism, as well as pharmacological and toxic reactions.” (Guandalini & Newland, 2011). The following list summarizes the identification of gluten sensitivity:
· Negative immune-allergy IgE tests to wheat
· Negative celiac blood tests- Endomysial Antibodies and/or tissue Transglutaminase in which IgA deficiency has been ruled out
· Negative endoscopic biopsy of the small intestine
· Presence of biomarkers of gluten immune reaction -Anti Gliaden Antibodies, IgA and IgG+
· Presence of clinical symptoms that can overlap with celiac disease or wheat allergy symptoms
· Resolution of the symptoms following implementation of a gluten-free diet
Research has concluded that gluten sensitivity, albeit gluten-induced, is different from celiac disease not only because it isn’t genetic but because the type of immune reaction is different. (Sapone et al., 2010) Recent research has demonstrated that “celiac disease and gluten sensitivity, are different clinical entities, and it contributes to the characterization of gluten sensitivity as a condition associated with prevalent gluten-induced activation of innate, rather than adaptive, immune responses in the absence of detectable changes in mucosal barrier function.” (Sapone et al., 2011)
According to Dr. Alessio Fasano of the CFCR, we should remember that gluten sensitivity is not rare, and cannot be distinguished from celiac on a clinical basis. It may present with vague non-specific symptoms and the gluten-free diet should be considered when all other forms of gluten reaction and other causes of the patient’s symptoms have been ruled out. It will be interesting to watch as research further clarifies the mechanisms of gluten sensitivity, its triggers and clinical implications. Meanwhile, this new category validates the experience of many clinicians and patients who have seen often dramatic clinical benefit from gluten elimination, unjustified by the former model of celiac and wheat allergy. It is interesting to note that gluten sensitivity is an immune mediated condition, so, there is still work to be done in defining gluten intolerance, which like lactose or fructose intolerance could possibly be enzyme mediated, not immune based. The gluten-free diet will no doubt continue to be the backbone of many therapeutic dietary interventions with often astounding results.
Referenences:
Catassi, C., Kryszak, D., Bhatti, B., Sturgeon, C., Helzlsouer, K., Clipp, S. L., Gelfond, D., et al. (2010). Natural history of celiac disease autoimmunity in a USA cohort followed since 1974 Annals of medicine, 42(7), 530–538. doi:10.3109/07853890.2010.514285
Guandalini, S., & Newland, C. (2011). Differentiating food allergies from food intolerances Current gastroenterology reports, 13(5), 426–434. doi:10.1007/s11894-011-0215-7
Jackson, J. R., Eaton, W. W., Cascella, N. G., Fasano, A., & Kelly, D. L. (2011). Neurologic and Psychiatric Manifestations of Celiac Disease and Gluten Sensitivity The Psychiatric quarterly. doi:10.1007/s11126-011-9186-y
Sapone, A., Lammers, K. M., Mazzarella, G., Mikhailenko, I., Cartenì, M., Casolaro, V., & Fasano, A. (2010). Differential mucosal IL-17 expression in two gliadin-induced disorders: gluten sensitivity and the autoimmune enteropathy celiac disease International archives of allergy and immunology, 152(1), 75–80. doi:10.1159/000260087
Sapone, A., Lammers, K. M., Casolaro, V., Cammarota, M., Giuliano, M. T., De Rosa, M., Stefanile, R., et al. (2011). Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity BMC medicine, 9, 23. doi:10.1186/1741-7015-9-23
|
|
