I always enjoy reading my university alumni magazines to check out the amazing things my college classmates have done, invented, or won. Indeed, today in my Columbia Alumni Magazine, I discovered a fascinating article "Against the Grain," by David J. Craig, that focused on one of my former professors who is an expert in Celiac Disease. I paid special notice because in the field of type 1 diabetes, Celiac disease often pops up. According to Dr. Peter Green, Director of Columbia University's Celiac Disease Center, United States physicians are only spotting 3 percent of cases. One such hypothesis is that Celiac disease is not treated with medications and has not attracted much interest from researchers due to financial concerns (Pharmaceuticals pay for approximately 80 percent of all medical research). After all, according to Dr. Green, "the pharmaceutical industry is not showing up to medical practice offices with samples of gluten-free food!"
A little medical history: According to Mr. Craig, Aretaeus of Cappadocia, the Greek physician, is credited with the identification of Celiac disease noting in the first century AD of a coeliac (Greek for abdomen) affection that made the stomach irrentive of food. The disorder is speculated to have appeared 8,000 to 12,000 years earlier when human hunter-gatherers began cultivating crops. (A Hidden Epidemic-by Peter Green, MD). According to Dr. Green, people living in what is now known as Syria crossed several types of grasses to produce wheat. Because of gluten's tendency to get sticky when mixed with water, wheat became an ideal ingredient to make bread. However, humans cannot breakdown gluten, thus the protein is usually just eliminated in the digestive tract in most people. In those with hyper-reactive immune systems, the gluten is considered a molecular invader and attacked, provoking an autoimmune response. 19th century scientists apparently noted a link between carbohydrates and celiac disease and finally in the 1940s, Dr. Willem-karel Dicke noted that many ill children in World War II who suffered from bread shortages, actually felt better! In the 1970s, blood tests were available to diagnose Celiac Disease. (For a full historical background, please consult Dr. Green's book.) According to the article, doctors in Europe continue to be the best at diagnosing Celiac disease due to the fact that many countries have nationalized health care systems to assist with preventive care. As physicians made more diagnoses, there was increased awareness and patient advocacy groups developed (as is happening now in the United States).
Green (and other authors) noted that approximately 30 percent of celiac patients have other autoimmune diseases. Of note in those with type 1 diabetes, a gluten free diet will often decrease the severity (i.e., improve blood sugar control) of other symptoms. Celiac disease is the only autoimmune disease in which researchers have identified the primary environmental trigger (Gluten). In the case of type 1 diabetes, as we know, there is no definitive trigger (of course, we know that viruses are one source). As I have mentioned previously, the total number of cases of type 1 diabetes and celiac disease are increasing dramatically.
Why is it so important to diagnose celiac disease and go on a gluten-free diet? According "The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing," McGowan, K.E, et al. in Pediatrics 2009; 124: 1572-1578, notes that children with undiagnosed Celiac disease remain at risk for complications including growth failure, anemia, osteopenia, delayed puberty, and/or autoimmune disease. In later years, infertility and malignancy may occur. Current North American guidelines recommend testing for celiac disease for multiple symptoms including GI complaints, chronic fatigue, short stature, delayed puberty, dental problems, increased liver enzymes, a skin condition called dermatitis herpetiformis, and nutritional anemias. Of course, in the endocrinology world, we always test for celiac disease in those with type 1 diabetes, Hashimoto's thyroiditis, Grave's Disease, IgA deficiency, Down's Syndrome, and Turner's Syndrome. In addition, clearly we would recommend testing a patient if there is a family history of Celiac Disease.
In McGowan's paper, the objective was to evaluate the impact of testing for endomysial IgA on the incidence and clinical presentation of childhood celiac disease in patients younger than 18 years, between 1990-1996 (pre-testing group-control) vs. 2000-2006 (testing group). The results were startling: the median age at diagnosis in the pre-testing group was 2 years compared with 9 years of age in the testing group. The incidence of celiac disease increased from 2 cases/100,000 children in the pre-testing group to 7.3 cases per 100,000 in the testing group. Thus, in conclusion, antibody testing for celiac disease tripled the incidence of celiac disease and quadrupled the median age at diagnosis. Lastly, the serologic testing was able to identify those children who presented with symptoms that were not necessarily typical for classic celiac disease or in many cases "silent celiac disease" without any symptoms.
The final message is to remember that autoimmune diseases often travel together...and screening is an essential tool even if one may have no symptoms of the disease. It is becoming more apparent that by diagnosis and treatment of one or more of these associated autoimmune diseases, the severity of symptoms and morbidity from the illnesses may improve considerably.