Sorting out gluten-related disorders

Behold, the hierarchy of gluten-related disorders.
As I discussed in my On Nutrition column in Sunday’s Seattle Times, there are various reasons that people may have adverse reactions to gluten. That’s because there is a spectrum of gluten-related disorders, and my little illustration above lays it out in an easy-to-digest visual (no pun intended).

Allergy

There are more than 50 different proteins in wheat. When someone has a wheat allergy, their body is reacting or one or more of those proteins. Specifically, the allergy-specific antibody immunoglobulin E (IgE) is causing the problem. Accordingly, that’s the antibody that tests for wheat allergy will look for. Wheat allergy symptoms come on relatively swiftly, within minutes to hours of eating wheat.
It is possible to have a wheat allergy but not be allergic to gluten. If this is the case, the sufferer would still be able to eat rye and barley, the other gluten-containing grains.

Auto-Immune

If you have an auto-immune disease, your immune system is attacking some part of your own body. That’s not good, because your immune system is supposed to be protecting your body. There are more than 80 different auto-immune diseases, a few examples are type 1 diabetes, rheumatoid arthritis, lupus Crohn’s disease and ulcerative colitis.

For people with auto-immune gluten-related disorders, the immune system is really trying to attack the gluten, but the lining of the small intestine gets caught in the crossfire.

  • Celiac Disease: The lining of the intestine becomes inflamed, and the villi, fingerlike projections that massively increase the ability of the intestine to absorb nutrients, become shrunken and flattened (atrophied). That causes all kinds of problems that can affect pretty much any and all of the body’s organ systems. Treatment is a 100% gluten-free diet for life.
  • Dermatitis Herpetiformis: A blistering skin rash that is also treated with a 100% gluten-free diet.
  • Refractory Sprue: A rare disorder that is similar to celiac disease, except that it remains unresponsive to treatment with a gluten-free diet after six months.
These disorders can develop over time, and there is not always an obvious time correlation between eating gluten and having symptoms…especially since symptoms themselves aren’t always obvious. I’ll talk more about the antibodies involved in auto-immune reactions to gluten in Thursday’s post.

Not Auto-Immune or Allergy

If these things happen in this order:
  1. Tests rule out wheat allergy and celiac disease
  2. A gluten-free diet results in improvement in symptoms
  3. Adding gluten back to the diet causes symptoms to return
Then…you may* have non-celiac gluten sensitivity. If so, the treatment is to avoid gluten. Eating gluten may cause intestinal inflammation but not actual damage, so the degree of avoidance is up to the individual. I can’t say this often enough: There is no test that can detect gluten sensitivity because there is no currently identified biological marker for gluten sensitivity.
Here’s a little visual overview of which symptoms tend to go with which gluten-related disorders.

*Tomorrow, I’ll talk about why it’s so important to get a correct diagnosis. As part of that discussion, I’ll give an overview of other health conditions that also affect the intestines and have some symptoms in common with those of celiac disease and non-celiac gluten sensitivity. Primarily, inflammatory bowel disease (IBD), which includes Crohn’s disease and colitis, and irritable bowel syndrome (IBS).
Note: These little graphics I made were inspired by slides in a wonderful education session given at te recent Washington State Academy of Nutrition and Dietetics conference by Cynthia Kupper, RD, of the Gluten Intolerance Group.