Introduction
The Immune System, Run Amuck

Celiac disease (CD), also known as celiac sprue, is a digestive disease that damages the small intestine and interferes with nutrient absorption. People with CD cannot tolerate gluten, a protein in wheat, rye, barley and oats. Mainly found in foods, gluten can also be found hiding in products such as medicines and cosmetics. Recognizing CD can be difficult because some of its symptoms are similar to those of other diseases including Irritable Bowel Syndrome (IBS), anemia, inflammatory bowel disease, and chronic fatigue syndrome. As a result, CD has long been under-diagnosed or misdiagnosed. As awareness of the multitude of symptoms associated with CD increases, diagnosing CD should become simpler. A diagnosis of CD used to mean a lifetime of horrible tasting foods, but thanks to advancements in the food industry, Celiacs can now choose from as varied a menu as anyone else.

When cells in your immune system are functioning correctly, they easily distinguish between helpful and harmful microbes they come into contact with. These cells make a determination about which bacteria, viruses, fungi and other potentially harmful substances they need to respond to and which are benign/beneficial. Many microbes and food sources are helpful, especially for digestion, so the immune cells leave them alone and let them get on with their business.

If, however, your cells determine that a substance needs to be eliminated, your body’s defense mechanisms kick into gear. This immune system response causes inflammation. Immune system cells, chemicals, and fluids flood to the site to overcome the offending substance. After the substance has been disabled or removed, the immune response ends. Inflammation subsides.

The Immune System, Run Amuck, cont.,
How The Actual Damage Is Done

When antigens enter your body, your immune system responds by producing antibodies specifically for and against them. This is called active immunity. It is your body creating a defense, unique to that antigen, so that the next time the antigen enters your body, a defense is ready and waiting to be executed. In a sense, it creates a catalogue of defenses for every antigen it’s come across so far. Taken one consideration further, it makes little difference whether the antigen invades the body under its own power or is introduced in the form of a vaccine. The response of the immune system is pretty much the same.

For some reason, as yet to be definitively defined by science, some people’s immune systems react inappropriately (autoimmune disease) and begin “defending” the body against helpful microbes, or indeed against the body’s own tissues, by mistake. And in some cases, the inflammatory response does not stop when it should. Either way, over time, this condition becomes chronic and damaging, resulting in injury to the intestines.

In the case of Celiac Disease (CD), the intestines are unable to absorb gluten and its respective parts. When gluten is consumed, it triggers the immune response, and over time, results in uncomfortable symptoms for the patient and serious damage to the intestines. Diagnosis can be a difficult, long and expensive process due to the large variety of symptoms associated with celiac disease.

Nearly all food absorption occurs in the small intestine. The small intestine is well suited for its function. Its wall has three structures that increase the absorptive surface tremendously – microvilli, villi, and circular folds.

How The Actual Damage Is Done, cont.,
Gluten-Related Disorders

Microvilli are tiny projections of the plasma membrane of the mucosa cells that give the cell surface a fuzzy appearance, sometimes referred to as the “brush border”.

Villi are fingerlike projections of the mucosa that give it a velvety appearance and feel, much like the soft nap of a Turkish towel. Within each villus is a rich capillary bed and a modified lymphatic capillary called a lacteal.

Digestive foodstuffs are absorbed through the mucosa cells into both the capillaries and the lacteal.

As CD progresses, if the consumption of gluten is not halted, the immune response to gluten becomes chronic resulting in constant symptoms and the destruction of villi. These villi are responsible for digesting and absorbing nutrients, minerals and the fat-soluble vitamins A, D, E, and K. Villi begin to flatten out and become ineffective (villous atrophy) causing symptoms of malabsorbtion, malnutrition and anemia.

A milder, more common and under-diagnosed version of gluten sensitivity is referred to as Non-Celiac Gluten Sensitivity (NCGS), occurring when there is no villous atrophy or damage to surrounding organs.

Sensitivities, Allergies, Intolerances, and Diseases
You see above you four different terms: sensitivity, allergy, intolerance and disease. Unfortunately for the seeker, these terms seem to be used interchangeably in today’s world, when, in fact, they can mean something altogether different from each other.

Gluten-Related Disorders, cont.,

For instance, you would think that a “sensitivity” to a substance is not as bad as an “intolerance”, basing your assumptions specifically on the implication of the common definitions of the two words. You might be “sensitive” to something and have a mild reaction, whereas an “intolerance” would indicate a more intense reaction and an avoidance of the substance altogether. Let’s delve deeper into the meaning of each of these four terms when taken in the context of gluten and CD.

What is a gluten sensitivity?
“Gluten sensitivity” belongs to a spectrum of disorders in which gluten has an adverse effect on the body. It can be defined as a non-allergic and non-autoimmune condition in which the consumption of gluten can lead to symptoms similar to those observed in Celiac Disease or wheat allergy (two other conditions which fall under the gluten-related disorders spectrum).

Symptoms: Bloating, abdominal discomfort, pain, or diarrhea, headaches and migraines, lethargy and tiredness, muscular disturbances, as well as bone and joint pain.

What is a gluten allergy?
A gluten allergy, like any other food allergy, is when your body’s immune system reacts against gluten, resulting in a histamine response with symptoms similar to a peanut allergy or hay fever. There is no known cause for a gluten allergy, any more than the known cause for any other food allergy. If you experience these symptoms, you may want to consult with your primary health care provider about them. *They will likely ask you to begin removing foods containing gluten from your diet for a period of time and then begin adding them back in again, one at a time, to see if your symptoms return. This will help you pinpoint the offending foods with more precision than just a blanket ban on all foods containing gluten. However, even though you may not have the classic symptoms of CD, you may be hindering your overall health by eating gluten and might want to rethink your food choices.

*If testing is required, your primary health care practitioner will not ask you to remove gluten from your diet as this could produce
a false negative.

Symptoms: Mouth ulcers, diarrhoea, skin eruptions, irritability, breathing problems, fatigue, bloating.

Gluten-Related Disorders, cont.,
Gluten-Related Diseases

What is gluten intolerance?
Probably more prevalent than actually documented, individuals can go through life with gluten intolerance and never understand what their symptoms are trying to tell them, and thusly never go for a formal diagnosis. Unfortunately, this leads to malabsorbtion, malnutrition, and more and more damage to the intestines every time gluten is consumed. A person with intolerance will generally feel unwell for a period of time after consuming gluten.

Gluten intolerance often has a slower onset that CD and may be harder to diagnose due to the broad range of symptoms and causes. Gluten intolerance can be exacerbated by emotional stress, infection, surgery, pregnancy and childbirth. The term “gluten intolerance” is used as an umbrella term for all manner of symptoms and extremes leading from a simple intolerance to CD.

Symptoms: Bloating, cramping, gas, diarrhea, headaches, nausea, eczema.

Gluten-related disorders can develop along the following three lines:

1. Autoimmune – can develop into:
   1. Celiac Disease
   2. Dermatitis Herpetiformis – an extremely itchy rash made of bumps and blisters. The rash is chronic, which means it continues over a long period of time. The cause is unknown however it is frequently linked to gluten sensitivity in the small bowel (celiac sprue). Symptoms can/will come and go but last for a long period of time when present.

Gluten-Related Diseases, cont.,
Can I Recover From Celiac Disease?

1. Autoimmune, cont.,…
   1. Gluten Ataxia – an immune-mediated disease triggered by the ingestion of gluten in genetically susceptible individuals. Symptoms include dizziness, disorientation, loss of balance, feeling “thick and foggy-headed”, and trouble concentrating. Ataxia means “lack of coordination in muscle action”.
      1. Gluten ataxia…can also affect fingers, hands, arms, legs, speech and even eye movements. Typical symptoms include difficulty walking or walking with a wide gait, frequent falls, difficulty judging distances or position, visual disturbances and tremor.
      2. “It’s best to describe gluten ataxia using the term gluten sensitivity because it takes one away from the misconception that you must have celiac disease to have any of these diverse manifestations,” says Marios Hadjivassiliou, MD, a neurologist at Royal Hallamshire Hospital in Sheffield, England.

2. Allergic – develops into a:
   1. Wheat Allergy – Wheat allergies manifest themselves in a wide variety of manners which can be different for different people. Some people experience hives while others might experience stomach pain. A wheat allergy, unlike a gluten intolerance, is considered a Type 1 Hypersensitivity. A wheat allergy may also sometimes occur as a cross-reactive condition related to an Oral Allergy Syndrome (OAS) which some people refer to as Pollen Foods Allergy Syndrome.

3. Not Autoimmune (Not Allergic) – becoming a:
   1. Gluten Sensitivity.

Because your body continues to identify gluten as the “enemy”,
the damage will continue unless a gluten free diet is followed.
While on a gluten free diet, your villi can, to some extent, heal
and begin functioning again and unless you regularly avoid gluten, the whole cycle will begin again.

Can I Recover From Celiac Disease? cont.,
Supplements for Celiacs

Although there is no cure for CD, there are ongoing studies for different therapies, some of which are showing great promise. Unfortunately, any marketable therapy is still years away.

In June, 2009 at the Digestive Disease Week medical conferences in Chicago, two research teams presented results of studies showing that people with CD who start the gluten free diet as adults don’t always have complete healing of the lining of their small intestine, even after they’ve been gluten free for a long time. In one presentation, researchers from the Mayo Clinic in Minnesota found that only 56% of adults on a gluten free diet, for less than two years, had healed intestines. Only 57% of participants who had been gluten free for two to five years had healed intestines. And of those participants who had been gluten free for more than five years, only 52% had intestinal healing. Lack of healing was slightly elevated in older age groups of participants and much more common in those who were not diagnosed until their villi had completely flattened out. Unfortunately, one of the conclusions of this study was that, even with a strict adherence to a gluten free diet, there is no guarantee of mucosal recovery. One of the reasons for this is hidden gluten sources in food products and incomplete labelling standards for gluten free products.

Children and Recovery
Have your children checked as soon as possible if symptoms begin to show. Studies have shown that up to 95% of children with CD may have complete healing of their intestinal lining within two years after starting a gluten free diet.

In addition to a gluten-free diet, people newly diagnosed with CD who have clinically evident malabsorbtion should initially receive a multi-vitamin, along with additional appropriate supplements, to correct any iron or folate deficiency.

Research shows that those of us with celiac disease/gluten intolerance often do have decreased absorption despite following a strict gluten free diet.

Supplementation for Celiacs, cont.,

Scott Adams summarized part of this research on celiac.com back in 2003. The article by Lee SK, et al. entitled Duodenal Histology in Patients with Celiac Disease after Treatment with a Gluten-free Diet implied that even though patients may feel better on a gluten-free diet, there may still be damaged intestinal areas that are incapable of optimal nutrient absorption. Since specific nutrients are absorbed along specific locations in the small intestine, this can have long-term ramifications. For instance, the proximal portion of the intestine is the site for absorption of vitamin B6 (pyroxidine). If that portion is damaged, there will be decreased absorption, and your body will be deficient in B6. You may then experience a range of neurological symptoms such as nervousness, irritability, and shakiness.

It makes sense to take complete digestive health into consideration rather than just worrying about your small intestine. Let’s take a look at four supplements you can add to your daily routine that will ensure optimal digestive health.

To help restore the intestinal lining, a supplement containing L-glutamine is necessary. Glutamine is a key amino acid that aids in restoring the intestinal lining. We already know that the intestinal tract is vital to our overall health as this is where nutrients are absorbed. The intestinal wall secretes mucus which forms a lining that covers the surface of the intestinal tract. A damaged intestinal tract lining is the underlying cause of many health problems, including food sensitivities. A healthy, functioning intestinal tract repairs itself approximately twice per week and one nutrient necessary for this process is L-Glutamine. A daily therapeutic dose of L-Glutamine soothes and helps heal the damaged areas more effectively. Nutter’s can suggest IntestiNew by RenewLife to help with L-Glutamine supplementation as it also contains ingredients which help reduce inflammation and promote healing of the intestinal tract.

The second important nutrient is omega-3. Omega-3 fatty acids reduce the inflammatory response and we’ve already learned that chronic inflammation is one of the causes of degeneration of your intestinal tract.

The third nutrient you should be adding is a probiotic. To read the full article on pre and probiotics, CLICK HERE. Probiotics restore healthy flora to your intestines and the more beneficial bacteria you have, the less likely harmful bacteria are to take up residence.

Supplementation for Celiacs, cont.,
The Celiac Blood Test

The fourth and last supplement to add to your diet is zinc. Zinc is a natural for healing wounds; that’s why you see it in topical creams. You can take too much zinc so taking it every other day is the best idea. If you’re already taking it in a balanced formula in a multi-vitamin every day, you won’t need to add any extra.

Bottom line? Stick to your gluten free diet as best you can, read labels and if you’re not sure about a product, put it back. And talk with your primary health care provider to work out a supplementation plan.

The Canadian Celiac Association has a great pamphlet outlining which tests are used for screening, if there is a genetic test, why your doctor might order another test, and so forth. Please use the aforementioned link to view this pamphlet online.

Before you start reading about which tests are used, it might help to stop here for a quick biology lesson.

In the beginning of this chapter we talked about antigens and antibodies. Antibodies are also referred to as immunoglobins, or Igs. Igs are grouped into five different classes, each with a slightly different structure and function. Those five classes are IgM, IgA, IgD, IgG, and IgE (just think of the name M.A.D.G.E.).

The Connection between IgA and Celiac Disease
IgA plays a critical role in mucosal immunity, bathing and protecting mucosal surfaces from the attachment of pathogens. More IgA is produced in mucosal linings than all other types of antibody combined. In fact, 75% of the total immunoglobulin produced in the entire body is secreted into the intestinal cavities each day. In the blood, IgA interacts (when deemed necessary) with a receptor to initiate inflammatory reactions. Since your villi (fingerlike projections covered with absorptive cells) live on your intestinal mucosa, you can be sure that any response or reaction directly affects them. A significant rise in IgA indicates a heightened immune response. If your body reads the presence of gluten to be harmful, it initiates the immune response.

Pre-Testing
Unless specifically told to, don’t go on any gluten-restrictive diets before you commence testing. This will give a false result and everything might appear falsely normal. Eat normally; eat everything you would generally eat in a day so that the test will accurately reflect what is happening to your body when you consume gluten.

Which Tests are Used
To summarize, there are 2 tests used to screen for celiac disease; either the IgA-human tissue transglutaminase (TTG) (more frequently ordered) or IgA-endomysial antibody test (EMA) (less frequently ordered), or a combination of both are recommended as screening tests. One test is no better than the other. In addition, your doctor may also order a serum IgA test which is used to evaluate IgA deficiency. If your body is making sufficient amounts of IgA, the TTG and EMA tests are approximately 90% accurate.

Blood tests are initially used to screen for the presence of celiac disease. The next step is an intestinal biopsy, which is a more definitive test. Biopsies are also done because of the 10% possibility of a falsely positive blood test. Biopsies best detect how much damage the intestinal villi have endured.

Blood tests can also be used to monitor the effectiveness of treatment; antibody levels should fall when gluten is removed from the diet.

Other blood tests might be ordered to determine other factors, including CBC to look for anemia, ESR and/or CRP to evaluate inflammation, or CMP to determine electrolyte, protein, and calcium levels and to ascertain the status of the liver and kidneys.

The Celiac Blood Test, cont.,
The Gluten Free Diet

When Are Tests Ordered

If you present with the large majority of the following symptoms for a significant amount of time, your doctor will most probably order testing:

• Abdominal pain and distension
• Iron-deficiency anaemia
• Bleeding tendency
• Bloody stool
• Bone and joint pain
• Changes in dental enamel
• Diarrhea
• Fatigue, weakness
• Flatulence
• Greasy, foul-smelling stools
• Mouth ulcers
• Vomiting
• Weakness
• Weight loss

When you first begin to eliminate/limit gluten from your daily routine, you might experience some real challenges. One of the best ways to avoid confusion and frustration is to educate yourself about, and come to a full understanding of, which foods and ingredients contain gluten. Unfortunately, you can run into a lot of different interpretations of what gluten-free means, depending on the product and the country where it was labelled. This can result in unnecessary avoidance of certain foods and ingredients and begin to needlessly restrict a one’s food choices.The Gluten Free Diet, cont.,

What a Gluten Free Diet Looks Like
Not unlike any other restricted diet, there are certain foods that should be avoided at all times, foods that can be eaten on occasion depending on the individual, foods that are worthy of further scrutiny (don’t take them at face value), and foods that are generally always acceptable. Don’t go by what others are eating. CD is a very personalized condition; everyone’s situation is different and requires individualized customization to maintain optimum health and comfort.

Foods that Require Further Consideration
Some foods need a second look. For instance, cheese spreads or sauces may be thickened with wheat flour or wheat starch, or the seasonings in these products may contain hydrolyzed wheat protein, wheat flour or wheat starch.

Foods to Avoid
Some foods, for obvious reasons (and some for not-so-obvious reasons), need to be avoided altogether. The Canadian Celiac Association has also put together a list.

Oats are causing a whole stir of their own (no pun intended).

The Gluten Free Diet, cont.,
The Gluten Free Kitchen

To read Health Canada’s Position on the Introduction of Oats to the Diet of Individuals Diagnosed with Celiac Disease, click here.

These are all advisory statements only, meant to help you make an informed decision. Your best call is still your own judgment, and the opinion of your primary health care provider, with regard to your personal situation.

If your whole family is taking part in a gluten free diet, your only consideration is to throw out any food products containing gluten, and wash out your cupboards and anything else you used for baking, cooking or eating off of.

If only certain members of your family are observing gluten free rules, the situation gets a little (but not much) more complicated. Store gluten free products in sealable containers on the shelves above all other foods so that no crumbs or dust falls from gluten-containing products onto gluten free products below. Do the same thing with utensils (put in sealed containers) in your drawers. Mark gluten free foods for kids with brightly coloured stickers so they can be identified by the kids as allowable for them.

For an entertaining video on how to construct a gluten free kitchen, click here. For more options, or to read about setting up a gluten free kitchen, click here.

For more information on how to set up a shared kitchen, making your kitchen gluten free, do you need to buy a new toaster and gluten free cookware and kitchen utensils, click here.

Allergy.
Hypersensitivity reaction to the presence of an agent (allergen) that is intrinsically harmless, such as … substances in certain foods.
– Barron’s Medical Guides, Dictionary of Medical Terms, Fourth Edition

Antigen.
Any substance capable of exciting our immune system and provoking an immune response. Most antigens are large, complex molecules that are not normally present in our bodies. Consequently, as far as our immune system is concerned, they are foreign intruders, or “nonself”.
– Essentials of Human Anatomy & Physiology, Seventh Edition, Elaine N. Marieb

Autoimmunity.
Production of antibodies against the tissues of one’s own body, producing autoimmune disease or hypersensitivity reactions.
– Barron’s Medical Guides, Dictionary of Medical Terms, Fourth Edition

Autoimmune Disorder.
Any of a large group of diseases marked by an abnormality of the functioning of the immune system that causes the production of antibodies against one’s own tissues and other body materials…
– Barron’s Medical Guides, Dictionary of Medical Terms, Fourth Edition

Definition of Celiac Disease
A chronic hereditary intestinal disorder in which an inability to absorb the gliadin portion of gluten results in the gliadin triggering an immune response that damages the intestinal mucosa – called also celiac sprue, gluten-sensitivity enteropathy, nontropical sprue, sprue.
– Merriam-Webster definition, posted on Medline Plus, A service of the U.S. National Library of Medicine, National Institutes of Health

Definition of Crohn’s Disease
A chronic inflammatory disease, primarily involving the small and large intestine, but which can affect other parts of the digestive system as well. It is named for Burrill Crohn, the American gastroenterologist who first described the disease in 1932. Genetic factors contribute to the causation of Crohn’s disease.
– MedicineNet.com

Definition of Gliadin (pronounced GLY-A-DIHN)
Gliadin is a glycoprotein present in wheat and several other cereals within the grass genus.
– Wikipedia definition of Gliadin

Endosperm.
An endosperm is tissue produced in seeds around the time of fertilization. The endosperm surrounds the embryo and provides nutrition in the form of starch. This make endosperm an important source of nutrition in the human diet as well. Wheat endosperm is ground into flour for bread.
– www.nutters.com, Gluten-Free Living Pages

Gluten.
A combination of two proteins; gliadin and glutenin. These two proteins coexist, along with starch, in the endosperms of some grass-related grains, notably wheat. 
– www.nutters.com, Gluten-Free Living Pages

– Gliadin
A glycoprotein (a carbohydrate plus a protein) within gluten. Gliadin is found in wheat and some other grains, including oats, rye, barley, and millet. People with celiac disease, Crohn’s disease, and other conditions may be sensitive to gliadin in the diet. In these conditions, antibodies to gliadin can often be detected in the blood. 
– MedicineNet.com

– Gliadin
Any of several prolamin proteins (simple proteins) present in wheat grains, and constituting a component of wheat gluten. Gliadins can cause celiac disease in susceptible individuals by inducing a destructive immune response in the small intestine. 
– The American Heritage Dictionary of the English Language

Glycoprotein.
A glycoprotein is a carbohydrate plus a protein.

Microbes
Small organisms, visible only under a microscope…
– Barron’s Medical Guides, Dictionary of Medical Terms, Fourth Edition

Prolamin.
Any of a class of simple proteins…found in the grains of cereal crops such as wheat, rye, barley, corn and rice.
– The American Heritage Science Dictionary

BOOKS and MAGAZINES

Gluten Free Diet: A Comprehensive Resource Guide
Written by Canadian, Shelley Case – a spot-on guide for Canadians.
www.glutenfreediet.ca

Cecelia’s Market Guide
A great guide to gluten free products to make it easier to shop for the newly diagnosed.
www.ceceliasmarketplace.com

“What’s Eating Your Child?”
by Kelly Dorfman
Here’s a book for every parent whose child suffers from mood swings, allergies, ear infections, eczema, anxiety, tantrums, ADD/ADHD, picky eating, lack of growth, and a host of other physical, behavioral, or developmental problems.

“Gluten-Free On A Shoestring”
by Nicole Hunn
Savvy mom and blogger Nicole Hunn shares her money-saving secrets, from bulk buying and coupon strategies to building meals around versatile, naturally gluten-free foods. She explains how to stock a gluten-free kitchen and gives the lowdown on the equipment readers really need.

Kids with Celiac Disease: A Family Guide to Raising Happy, Healthy Gluten Free Children
By Danna Korn
A practical guide for the families of children and teenagers with celiac disease, a chronic, life-long digestive disorder.