Are your patients complaining of bloating, abdominal pain, brain fog, or fatigue? Perhaps you run a stool test and find that after treating the abnormal results, the patient’s symptoms continue. Or perhaps you have treated your patient many times for dysbiosis only to have it return again and again. At this point, it’s wise to consider that your patient may be reacting to a common dietary component such as wheat.
A number of wheat-related disorders can affect the health of patients. These include celiac disease, wheat allergy, non-celiac gluten sensitivity and non-celiac gluten intolerance. Celiac disease, non-celiac gluten sensitivity, and non-celiac gluten intolerance don’t always manifest with gastrointestinal symptoms. In fact, extraintestinal symptoms of gluten reactivity are far too common, which is one of the main reasons they are missed by practitioners. Celiac disease and gluten reactivity are not captured by standard food sensitivity tests. This is why testing for celiac and gluten reactions (above and beyond food sensitivities) is necessary to resolve unexplained chronic illnesses.
In this blog post, we’ll address the most clinically useful tests for celiac disease. While there is no diagnostic test for gluten intolerance/gluten sensitivity, an immune reaction to gluten on testing can provide clinical rationale to put a patient on a gluten elimination trial. We will also review the best treatments for patients with wheat-related problems. Hint: Removing gluten from the diet isn’t always enough.
However, first we’ll review the differences between celiac disease, wheat allergy, non-celiac gluten intolerance and sensitivity.
What Is Celiac Disease?
Celiac disease is a genetic autoimmune disorder that affects the small intestine. When a person with celiac disease is exposed to gluten, the immune system mistakenly goes after this protein and in doing so damages the healthy cells lining the small intestine. This leaves the small intestine unable to absorb nutrients from food. It’s estimated that 1 in 133 people have celiac disease, but recent screening studies in children with no celiac symptoms or risk factors indicate the prevalence may be higher. Patients with celiac disease are up to 34% more likely to develop other autoimmune diseases.
Gluten contains two main proteins – glutenin and gliadin – but gliadin is mainly to blame for the adverse effects of eating gluten. Gluten is found in a number of food items including wheat, barley, spelt, kamut, and rye. It can also show up in products like lip balms, lipsticks, toothpastes, some dietary supplements, and occasionally in medicines. Celiac disease patients can also react to foods that cross-react with gluten (more on this later).
Celiac disease symptoms can include:
- Abdominal pain
- Bone or joint pain
- Brain fog
- Chronic fatigue
- Impaired spleen function
- Loss of bone density or softening of bone
- Mouth ulcers
- Skin rash
- Tingling in the hands or feet
- Weight loss
Children with celiac disease are more likely to have digestive problems compared to adults. In addition, wheat-related disorders can manifest in significantly different ways in different patients, varying from gastrointestinal, metabolic, musculoskeletal, neuropsychiatric, reproductive, and skin-related symptoms.
What Is Wheat Allergy?
A wheat allergy is a type of food allergy that is usually mediated by an IgE antibody response to wheat. People who are allergic to wheat can experience itchy eyes or have difficulty breathing after dietary exposure. In this group of patients, unlike celiac disease, exposure to wheat doesn’t cause long-term damage to the small intestine. Diagnosis of wheat allergy usually occurs through IgE antibody testing, but non-IgE-mediated wheat allergies can occur.
The Difference Between Gluten Sensitivity and Celiac Disease
The terms non-celiac gluten intolerance and gluten sensitivity are often used interchangeably. In these disorders, a patient doesn’t feel well after eating gluten. They may have the symptoms of celiac disease with none of the positive blood markers or small intestinal abnormalities.
Gluten intolerance and gluten sensitivity symptoms include:
- Abdominal pain
- Brain fog
- Joint pain
- Skin rash
According to the Cleveland Clinic, an estimated 6% of people in the United States have non-celiac gluten intolerance.
Usually, celiac disease and wheat allergies are ruled out as a cause of a patient’s problems before the possibility of gluten intolerance/sensitivity are explored.
Celiac and Gluten Intolerance Testing Should Expand to a Wider Group of Patients
Most functional medicine providers will implement celiac testing in patients who have the characteristic symptoms. However, new evidence indicates that the net should be cast wider. For example, there is a high prevalence of celiac disease in patients with type 1 diabetes. Duodenal biopsies indicate that 10% of people with type 1 diabetes have celiac disease. In a large study of children with type 1 diabetes, 60% were seropositive for celiac at diabetes diagnosis and the remaining 40% were given a celiac diagnosis four years later. In adults with type 1 diabetes, 42% were diagnosed with celiac disease within 10 years of their diabetes diagnosis.
Liver disease is also common in patients with CD, especially primary biliary cirrhosis and a mild type of hepatitis known as celiac hepatitis. This is thought to occur due to gluten-induced intestinal permeability, which leads to contamination of blood flow to the liver and exposes the liver to toxins, bacteria, lipopolysaccharides, and inflammatory cytokines that originated in the gastrointestinal tract.
Neurological and psychiatric problems are another group of conditions associated with wheat-related disorders. This signals that gluten exposure in these patients may damage nerve tissue. One case study found that a three-year-old girl with a conjunctival tumor also had celiac disease. When the girl was placed on a gluten-free diet, her tumor resolved.
Best Celiac Disease and Gluten Sensitivity Tests
Traditionally, the gold standard for celiac disease testing was a small intestinal biopsy to detect total villous atrophy, damage to the microscopic villi that line the small intestine. However, celiac disease develops in stages and total villous atrophy is the end-stage of the disease. Detecting celiac disease before it progresses to villous atrophy is therefore an ideal approach.
It’s also best to keep in mind that genetic testing for celiac disease does not always identify with accuracy the presence of this disorder. Ninety to 95% of patients with celiac disease are positive for the HLA-DQ2 gene and 5% to 10% are positive for the HLA-DQ8 gene. However, new evidence suggests that not every celiac patient has these genetic markers. In fact, 7% of people with celiac disease are not positive for either of these two genes.
Consequently, because biopsies and genetic testing have drawbacks, a combination of multiple tests for celiac disease or gluten reactivity may be best. The following tests can also be used to diagnose celiac disease or help determine if a patient has another wheat-related disorder.
Blood Tissue Transglutaminase IgA and IgG Testing
Tissue transglutaminase autoantibodies have a 95% sensitivity and specificity at detecting celiac disease. Tissue transglutaminase is a protein involved in processes such as wound healing, inflammation, and autoimmunity. It plays a major role in the development of celiac disease and triggers the immunogenicity of gluten peptides in the small intestine. Tissue transglutaminase is considered the primary screening test for celiac disease.
Rupa Health offers access to anti-tissue transglutaminase antibody serum testing such as the tissue transglutaminase IgA and IgG testing provided by Access Medical Laboratories. Another option is Genova diagnostics Celiac Panel, which includes anti-tissue transglutaminase IgA and IgG along with anti-endomysial IgA – an antibody against endomysium, which is part of the smooth muscle connective tissue. Anti-endomysial antibody testing has a sensitivity and specificity of > 95% for detecting total villous atrophy in celiac disease. However, its ability to detect partial villous atrophy has a sensitivity as low as 27% to 31%.
Anti-Gliadin Antibody Testing
Anti-gliadin antibody levels are diagnostic for celiac disease and help to monitor gluten-free dietary compliance. High levels of anti-gliadin antibodies also correlate with small intestinal damage seen in celiac disease. Anti-gliadin IgA and IgG antibody serum testing can be ordered as a single marker or as part of a celiac panel through Rupa Health. Fecal anti-gliadin antibody (like in the GI-MAP) is sometimes measured in stool as an indicator of gluten reactivity in the lumen of the gut.
Vibrant Wheat Zoomer Test
This serum or blood spot test offers a comprehensive understanding of a number of markers for intestinal permeability, gluten- and wheat-related food sensitivities and allergies, and celiac disease. It measures 24 different markers including anti-tissue transglutaminase IgA and IgG, zonulin (a marker of intestinal permeability), wheat IgE, anti-wheat germ agglutinin IgG/IgA, and alpha, beta, gamma, and omega gliadin.
Testing for Cross-Reactive Foods
Some patients who react to gluten also are affected by cross-reactivities to other foods that contain proteins similar to gluten. These foods include:
This explains why some people on a strict, thorough gluten-free diet are not experiencing improvement. Cyrex’s Array 4 tests for gluten-associated cross-reactive foods and food sensitivities with IgA and IgG antibodies. Food sensitivity panels may also help uncover cross-reactive foods or food sensitivities that might be getting in the way of a patient’s healing process. An IgG food sensitivity panel can identify which foods a patient reacts to. Labs offering food sensitivity tests through Rupa include Alletess Medical Laboratory, Cyrex, Genova, US BioTek, Vibrant Wellness, and more.
Effective Treatments for Celiac, Gluten Sensitivity, and Gluten Intolerance
Removal of Gluten and Gluten-Cross-Reactive Foods
The only way to completely heal the small intestine in celiac patients is to completely remove gluten from the diet. This is easier said than done. Even trace amounts of gluten may aggravate a person with celiac or non-celiac gluten sensitivity. Unfortunately, there are many hidden sources of gluten that most practitioners and patients aren’t aware of. If hidden gluten exposure is ruled out, consider removing gluten-cross-reactive foods and beverages to which a patient may react. An elimination diet removing foods specified on a food sensitivity test can be useful in improving the symptoms of patients with either celiac disease or non-celiac gluten sensitivity/intolerance.
DPPIV Enzyme Formulas
Enzyme formulas can help patients digest gluten, including 10 to 1,000 mg of hidden dietary gluten. Dipeptidyl peptidase IV (DPPIV) is an enzyme that normally exists in the small intestines and colon where it is involved in the hydrolysis of prolyl peptides and the absorption of proline-rich proteins. In patients with celiac disease and those in remission, DPPIV levels are low. Enzymes with DPPIV activity can assist with the rapid clearance of short gliadin prolamine peptides and especially the most immunogenic epitopes from alpha-gliadin. Peptidase and protease enzymes should be taken together with enzymes with DPPIV activity since they help digest gluten into prolamine fragments, making it easier for the DPPIV to do its work.
Gut Health Supplements
Other dietary supplements known for their ability to support digestion and heal the gut include probiotics, digestive enzymes, and L-glutamine.
Surprisingly, a gluten-free diet may potentially lead to a reduction in the populations of beneficial Bifidobacterium and Lactobacillus species, while possibly increasing levels of opportunistic pathogens such as Escherichia coli and Enterobacteriaceae. Patients on a gluten-free diet may therefore benefit from probiotic supplementation and a diet rich in fiber and prebiotic foods.
Many functional medicine providers also use digestive enzymes to heal the gut. Additionally, the amino acid L-glutamine is a well-known gut-healing supplement. It supports intestinal permeability by maintaining tight junction proteins. In athletes who run in the heat, which can increase intestinal permeability, supplementing with L-glutamine led to a stronger intestinal barrier.
Patients who have symptoms of celiac disease or non-celiac gluten sensitivity/intolerance can benefit from several forms of testing. Always keep in mind that gluten-related disorders can manifest as both gastrointestinal and extraintestinal symptoms, which is why patients with type 1 diabetes, liver disease, and ocular and nervous system problems may benefit from excluding gluten from their diets. There are many tests for celiac disease and a combination may be ideal for identifying hard to diagnose celiac patients. While there is no diagnostic test for non-celiac gluten sensitivity, tests that measure the immune system’s reaction to gluten can help identify a patient that may benefit from gluten removal: tissue transglutaminase autoantibodies, anti-gliadin antibody testing, antibodies to wheat peptides, and testing for cross-reactive foods. Elimination diets, rooting out hidden sources of gluten, enzymes to help digest gluten, and gut-healing supplements can all assist with restoring whole body health in the gluten sensitive patient.
Rupa Health helps practitioners take the guesswork out of the labwork experience. Clinicians can order, track, and get access to 20+ lab companies in one place, at no extra cost. Choose from a variety of laboratories that test for wheat-related disorders, including:
- US BioTek
- Vibrant America
- Vibrant Wellness