A diagnosis that can be upsetting.

Many people worry about the dietary limitations and restrictions. However, there is no reason for concern. Even though it means following certain rules, life with the coeliac condition can be lived with intensity and enjoyment. A coeliac need not make any compromises in quality of life!

The coeliac condition is a permanent dietary intolerance to gluten.

Gluten is a protein that is present in wheat and other cereals, such as oats, barley, rye, emmer, kamut, spelt and triticale. In a genetically predisposed subject of any age, the ingestion of even small quantities of foods containing gluten triggers an immune response in the small intestine, causing a chronic inflammation. This in turn causes the eventual disappearance of the intestinal villi. This process is accompanied by a range of symptoms that vary from person to person. In a healthy individual, the intestinal wall is covered with villi and microvilli, the function of which is to increase the surface area of the intestine to aid the absorption of nutrients. In the coeliac, however, these villi are greatly reduced and the mucous lining of the intestine is damaged. Because of the decrease in surface area, the absorption of nutrients such as protein, fats, carbohydrates, vitamins and minerals is inhibited, leading to malnutrition and loss of function. Gluten intolerance is one of the most common conditions worldwide. In countries with a population of primarily European origin (in Europe, North and South America and Australia), approximately one out of every 100 people is affected. A similar frequency has been reported in developing regions, such as North Africa, the Middle East and India, where large quantities of wheat are consumed.

Gluten is a protein substance that is present in certain cereals, such as wheat, oats, barley, rye, emmer, kamut, spelt and triticale. Gluten has very little nutritional value. In fact, the main function of this protein is to act as a bonding agent, that is, to cause flour to cohere, which makes possible the baking of bread.

The coeliac condition has a complex pathology that is caused by a variety of hereditary and environmental factors.

Genetic factors
That the coeliac condition has a genetic component is demonstrated by the fact that it tends to run in families. Family members of coeliacs are approximately ten times more likely than the general population to suffer from the condition. However, not all of the numerous genes that contribute to a hereditary predisposition are presently known. The best-understood factors belong to the human leukocyte antigen (HLA) system, a complex of genes that “recognise” molecules foreign to the organism. The HLA-DQ2 and/or DQ8 genotypes are present in the vast majority (at least 95 per cent) of coeliacs. The presence of HLA-DQ2/DQ8 alone, however, does not necessarily lead to a development of the illness, as these same genes are found in a high percentage of healthy subjects (20 to 3 0 per cent of the general population).

Environmental factors
The environmental component of the coeliac disorder is an exposure to gluten in the diet.

The symptoms of the coeliac condition can vary. In some cases, the affected person may feel no symptoms at all.

The most common manifestations are diarrhoea, weight loss and general weakening, abdominal bloating and abdominal pain, vomiting, and, in children, retardation of growth. Other symptoms can manifest themselves outside the intestine, such as anaemia, osteoporosis, amenorrhea and vitamin or mineral deficiencies. Some symptoms come from pathologies that are associated with the condition. The coeliac condition does not always present itself in the same way, however; it has various clinical forms, and these must be taken into account during the diagnostic phase. The various clinical manifestations of the coeliac condition can be divided into typical cases with marked gastrointestinal symptoms (these cases are in the minority today) and the more frequent atypical cases, which are characterised by vague symptoms such as colitis (the so-called “irritable bowel”) or an iron deficiency that is resistant to oral therapy. There are also the silent forms, which are occasionally diagnosed in subjects at risk (family members of coeliacs, for example, or diabetics who are subjected to serological screening) despite the absence of obvious symptoms. In such cases, the apparent lack of symptoms is misleading; after treatment begins, a marked improvement in overall well-being is noted. Finally, the condition is suspected in some patients because they have a non-intestinal complaint that may be associated with the coeliac condition, such as dermatitis herpetiformis, aphthous stomatitis, diabetes, osteoporosis, fertility disorder, thyroiditis, allergies, food intolerance, or a neurological pathology. In individual – fortunately very rare – cases, the coeliac condition manifests itself from the onset with severe complications such as ulcerative jejunoileitis or intestinal lymphoma.

There are four ways in which the coeliac condition manifests itself.

The typical coeliac condition
The typical forms of the coeliac condition begin early, generally within a few months of the start of weaning, with symptoms of intestinal malabsorption: chronic diarrhoea, retardation of growth, lack of appetite, vomiting, and abdominal distension (“bloated belly”).

The atypical coeliac condition
The atypical forms of the coeliac condition manifest themselves late with predominantly non-gastrointestinal symptoms, such as irondeficiency anaemia, an increase in hepatic transaminase, recurring abdominal pains, dental enamel hypoplasia, dermatitis herpetiformis, or short stature in schoolaged children.

The silent coeliac condition
The silent forms of the coeliac condition are diagnosed by chance in apparently healthy subjects as the result of an examination. Many cases are silent only in appearance; after beginning treatment, subjects register a marked improvement in psychological and physical wellbeing.

The potential coeliac condition
Cases are defined as potential or latent if they present positive serological markers but normal intestinal biopsies. Patients with latent coeliac condition, if left on an unrestricted diet, may in time develop a full-blown intestinal lesion. An elevated occurrence of the coeliac condition, often in an insidious form, is found in subjects affected with autoimmune pathologies (especially insulin-dependent diabetes and thyroiditis), syndromic pathologies (Down’s syndrome, Turner’s syndrome and Williams syndrome), or a deficiency of serum immunoglobulin A (IgA).

In the presence of symptoms that can be associated with the coeliac condition, an initial diagnosis of gluten intolerance can often be obtained on the basis of blood tests alone. A definitive diagnosis, however, can be made only on the basis of an intestinal biopsy. In this procedure, a tissue sample from the small intestine is collected and then subjected to a histological exam, which can reveal possible atrophy of the intestinal villi.

Blood tests
Certain blood tests may confirm a suspicion of coeliac condition. Primary among these is the highly reliable and automated test for antitransglutaminase antibodies (antitTG) of the IgA class. An equally effective, though less widespread, test is for anti-endomysial antibodies (EMA). Tests for antigliadin antibodies (AGA) of the IgA and IgG classes are particularly conclusive in children under the age of three. An isolated change in AGA-IgG does not generally carry diagnostic weight except in children with a deficiency in serum IgA.

Intestinal biopsy
In the event that the blood tests are positive, the next step is to perform an intestinal biopsy, a procedure in which a tissue sample from the small intestine is taken by means of an endoscope and then analysed. If the characteristic alterations in the intestinal lining (atrophy of the villi and an increase in intraepithelial lymphocytes) are found, a definitive diagnosis of the coeliac condition can be made.

The gluten challenge
In cases of doubt, it is customary to carry out a gluten challenge, which involves re-exposing the subject to gluten after at least two years of dietary treatment. The diagnosis of coeliac condition is confirmed if the test, which is done under medical supervision, causes a clinical and histological relapse within a span of several months or, rarely, over a period of years.

Two illnesses with a common origin, one balanced diet to treat them both.

Between five and ten per cent of patients with Type 1 (insulindependent) diabetes are also affected by the coeliac condition. In order to treat these two diseases together, it is necessary to maintain a vigilant diet, but one that does not need to be highly restrictive. Today, in fact, the diabetic, either with or without an associated coeliac condition, is advised to maintain a normal diet with regard to both the total caloric content and the level of protein, sugars, and fats. In order to avoid a spike in blood sugar levels after meals, it is recommended to favour complex carbohydrates (bread and pasta that is, of course, gluten-free) and foods that are rich in fibre (vegetables, pulses, and fresh fruit) over those that are high in sugar (sweets), which may be consumed but in moderation. With regard to fats, it is best to select those of vegetable origin (such as extra-virgin olive oil and sunflower oil) and those rich in polyunsaturated fatty acids (such as anchovies, sardines, and mackerel) for their beneficial effect upon the levels of cholesterol in the blood. Finally, it should be kept in mind that the treatment of the coeliac condition has a very positive effect upon diabetes, both because it helps to improve metabolic control and sometimes even to reduce the need for insulin, and because it helps to prevent possible complications such as anaemia and osteoporosis.

It manifests itself with the coeliac condition, but it has different causes.

Before and after their coaliac condition is diagnosed, coeliacs may also present with an intolerance to lactose caused by the presence of a diffuse lesion of the intestinal lining. Nevertheless, a reduced tolerance to lactose may persist even after the beginning of the treatment of the coeliac condition, when the structure of the intestinal lining has already normalised. This situation is caused by a lack of enzymes that is genetically based. This is very frequent in the general population, especially in the countries of southern Europe, and has nothing to do with the coeliac condition itself. In these cases, the consumption of foods which are rich in lactose, especially whole cow's milk, may cause persistent symptoms such as abdominal pain and flatulence. The treatment of this condition requires the avoidance of foods that are rich in lactose, such as whole milk and dairy-based ice cream. In place of whole milk, it is advisable to consume products low in lactose, which are nowadays available in all supermarkets. Since the intestine retains the capacity to digest limited quantities of lactose, other dairy products such as yoghurt, cheeses and milk biscuits are generally well tolerated in less severe cases.

A strict gluten-free diet is the only effective therapy.

A strict gluten-free diet is currently the only effective therapy that guarantees coeliacs a perfect state of digestive health, characterised by the disappearance of clinical symptoms, a normalisation of test results, and a restoration of the normal structure of the intestinal mucous membrane (mucosa). In the treatment of the coeliac condition, all foods containing wheat derivatives, including lesser-known varieties, must be banned from the diet. It is crucial to keep in mind that even small quantities of gluten can cause damage. Careful attention must be paid to the ingredients of common foods on the market, since traces of gluten may be present in various products. The dietary therapy is facilitated by the availability of a vast range of products (including bread, pasta, biscuits, pizza dough and baking flour) suitable for coeliacs. For ease of identification, these products bear the symbol of a stalk of grain that has been crossed out, a mark that guarantees the absence of gluten. In order to make the management of the coeliac diet even simpler, national coeliac associations have compiled handbooks (food lists) of “safe” commercial foods, and these publications are updated periodically.

Learning how to identify gluten-free foods.

Ever since the European Union issued its recent directive on labelling, it has become easier to identify “risky” foods. The directive requires food producers to declare the presence of even minute quantities of gluten in their products. Often, the deliberate or involuntary ingestion of trace quantities of gluten will not provoke an immediate irritation, but it may be harmful over the long term because of the risk of persistent intestinal inflammation. It is therefore critical to remain vigilant while on the diet. Nevertheless, there is absolutely no need to engage in gluten phobia or excessive dietary anxiety.

Safe foods, or foods without gluten
Numerous naturally gluten-free foods exist that may be consumed without reservation. These include rice; maize; various types of starches, such as potatoes, pulses, buckwheat, manioc, tapioca, and chestnuts; milk and dairy products; meat; fish; eggs; vegetable oils; vegetables; and fruit. In addition, there is a vast range of processed foods (including bread, pasta, biscuits and cereals) that caters especially for the dietary needs of coeliacs. These foods can be identified by a crossed-out grain stalk on the package, a symbol that guarantees the absence of gluten.

Risky foods
Certain foods may be consumed only after one has made sure that they are free of gluten. Even so, they cannot be considered 100 per cent safe: even though gluten may not appear on the list of ingredients, some contamination may have occurred during the production process. Risky foods include instant soups, sausages, soy sauce, meat flavouring mixes, candies and sweets, ice cream, starch, maltodextrin, glucose syrup and malt.

Prohibited foods
Foods that must be eliminated completely include all those containing derivatives of wheat and certain other cereals, including emmer, kamut, triticale, spelt, barley and rye. Oats are not recommended, as they are often contaminated with gluten.

The first effect is a cessation of clinical symptoms.

The beginning of the diet is associated with the disappearance of clinical symptoms, the normalisation of antibody tests and the restoration of the normal structure of the intestinal lining. In subjects with typical symptoms, the effects of the treatment are astonishing: within a few days, there is a marked improvement in mood and appetite, followed by the progressive amelioration of diarrhoea and, in children, resumption of growth. Also, metabolic complaints, such as osteoporosis or iron-deficiency anaemia, tend to resolve themselves gradually. The diet, especially if adopted at an early stage, minimises the risk of long-term complications, but it does not completely nullify the possibility of associated autoimmune disorders. These include autoimmune thyroiditis (Hashimoto’s thyroiditis), a disease that is rather common during puberty, particularly in females.

The advantages of a gluten-free diet:

• the intestine returns to normal
  
• nutrients are absorbed and utilised by the organism
  
• lost weight is regained
  
• psychological and physical wellbeing is restored

The gluten-free diet is healthy, tasty and balanced.

For the well-being of the whole body, it is advisable to eat a variety of foods, drink plenty of water, and use salt in moderation. A varied diet is important. A guide to the optimal composition of one’s daily diet is provided by the so-called “food pyramid”. This pyramid is divided into six sections, each containing one food group. Sections at the base of the pyramid represent foods that should take up a large part of the diet (these include cereals – gluten-free, of course – and potatoes), while those at the apex (namely fats) should be consumed in small quantities.

The following menu is an introductory guide for the initial period of the diet. The dishes listed here are simple to prepare and can be readily incorporated into one’s dietary regimen. There are also numerous cookery books on the market. They can help you give free rein to your imagination while maintaining a gluten-free diet.

The building blocks of nutritional health.

Fruit and vegetables: 5 times a day
These foods are a source of fibre, vitamin A, vitamin C, other vitamins, and minerals. This group also includes fresh pulses. It is advisable to consume 3 portions of vegetables and 2 portions of fruit every day.

Cereals and potatoes: at every meal
Gluten-free bread, pasta and cereals, and potatoes and rice are an important source of carbohydrates and fibre in the form of starch, and thus are converted readily into energy. Eat at least one of these foods at each meal of the day.

Meat, fish, pulses and eggs: once a day
1-2 portions of meat, fish and eggs: preferable types are lean beef, poultry, pork and fish, and eggs 2 -3 times a week. These foods provide trace elements, protein and B-complex vitamins. This group also includes dried pulses (beans, chickpeas, dried peas and lentils).

Dairy products: every day
Dairy products such as milk, yoghurt and cheese are rich in proteins and vitamin B2, and supply the body with calcium. 1-2 portions of 120g each a day are recommended, preferably low-fat varieties.

Fats and condiments; every day but in moderation
1-3 portions of fats and oils: preferable are those of vegetable origin (especially extra-virgin olive oil), although those of animal origin (butter, cream, lard, bacon fat, etc.) may also be used. They are sources of fatty acids and fat-soluble vitamins (A, D, E, K) that aid in absorption.

Useful advice for proper nutrition
Additional hints:

• drink at least 1-2 litres (1-2 quarts) of water per day. Recommended beverages are mineral water, diluted fruit and vegetable juices, and unsweetened herbal teas and fruit teas
  
• keep food preparation healthy and avoid adding fats (try roasting, boiling, steaming, or sautéing)
  
• eat slowly, chew well and savour the food
  
• use more fresh herbs than salt
• consume alcohol in moderation
  
• use sugar sparingly
• use only gluten-free ingredients when following a recipe
  
• avoid contamination with foods that contain gluten
  
• get regular exercise

How to prepare a safe meal without gluten.

Select ingredients that are reliably gluten-free. It may be helpful to consult a list of products recommended by coeliac associations.

• Never touch the food with flourcoated hands or with unwashed utensils (bowls, ladles, strainers, pots, etc.) that have been in contact with prohibited foods.
  
• Do not place the food directly on contaminated surfaces, such as the countertop, baking pans, the bottom of the oven, hotplates or the grill. Clean everything well before beginning work.
  
• Do not reuse oil that has already been used to fry flour-coated or breaded food.
  
• Do not reuse water that has already been used to cook pasta with gluten.
  
• Use greaseproof paper (wax paper) or aluminium foil on plates and surfaces that may have been contaminated.

Counteracting possible dietary deficiencies and associated intolerances.

The gluten-free diet, which has now been used to treat the coeliac condition for more than 50 years, is a nutritional regimen that is appropriate for all age groups, even in special situations (such as pregnancy or diabetes). The necessity of excluding foods derived from wheat may, however, lead to a less-than-optimal intake of vegetable fibre. One may compensate for this by consuming an adequate amount of fresh fruit and vegetables every day. It is also important to ensure a sufficient intake of vitamins, particularly of the B complex, and calcium.

Research on a therapeutic solution is still underway.

The goal is to allow patients to free themselves from the “burden” of the gluten-free diet. Studies are being conducted, for example, on less toxic varieties of grain, on enzymes that are capable of metabolising the protein elements that are hardest for coeliacs to digest, and on anti-transglutaminase or anti-cytokine and immunomodulatory drugs capable of blocking the abnormal response to gluten (similar to a vaccine). At present, tests on the efficacy of these potential alternative treatments are still at a very early stage. Among other things, the progress of the research from the laboratory to clinical trials is slowed by the absence of an animal model for the coeliac condition. While it is easy to envision a rosier future for coeliacs, predicting a time frame for the completion of the research is more difficult. It must be stressed that any new treatment will have to prove itself to be better than the existing one, namely the safe, effective, and readily available gluten-free diet.

After one to two years of the diet, no further tests are necessary.

In fact, if no doubts exist regarding the original diagnosis, it is not considered necessary to verify the normalisation of the intestine by biopsy. However, it is advisable for the patient to have periodic checkups at a specialised centre. There, certain laboratory tests can help to indicate the patient’s health status.
These include in particular:

• indicators for iron metabolism (blood count, serum iron and ferritin). Any persistent iron deficiency can be addressed with an oral supplement;
  
• anti-tTG antibodies. If positive, this test indicates poor attention to the diet;
  
• tests for the early diagnosis of existing or suspected autoimmune pathologies (especially for the detection of antithyroglobulin and anti-thyroid peroxidase antibodies, indicators of thyroiditis).
  

The most difficult hurdle to overcome is the initial diagnosis.

It is often said that, once it is diagnosed, the coeliac condition is no longer an illness but merely a fact of life. Although one’s psychological and physical state improves considerably after treatment begins, one still has to learn to live with the rules imposed by the new dietary regimen. The wide variety of glutenfree products recently made available by the speciality food industry has contributed substantially to improving the quality of life for coeliacs. Gluten-free products are more and more readily available in supermarkets, either in prepared form or as ingredients to use in cooking. The burden of the dietary restrictions becomes especially noticeable, however, when meals are consumed away from home, because the availability of gluten-free dishes and snacks is still limited in restaurants, bars and cafeterias. This situation is, however, getting better year by year, thanks to the dedicated efforts of coeliac associations and the growing attention of institutions and the mass media.

Life at school
Many schools can assure the provision of safe meals for coeliac children, but it is nevertheless important for parents to verify personally that the teachers and the kitchen staff are knowledgeable about the problem. The wide availability of gluten-free snacks, both sweet and savoury, makes it easy to deal with situations such as school outings and birthday parties.

Adolescence
Stresses on the diet are much more common during adolescence, as many teenagers have a hard time accepting and, above all, revealing to others their dietary differences. Frequently, the absence of symptoms may encourage a tendency to cheat on the diet from time to time. What should be done in such cases? It is best to avoid blaming or, even worse, intimidating the adolescent. The most constructive approach is to focus on correct information and on behaviours that encourage adherence to the diet. In certain cases, particularly if there is conflict between the young patient and his or her parents, it may be advisable to get professional psychological help. The difficulties of adolescence are generally passing. As time goes by, most young people will achieve the goal of living comfortably with the coeliac condition.

Both are possible, as only those with the genetic predisposition can develop this condition but, on the other hand, the condition is only developed after having introduced gluten into the diet, because otherwise the abnormal mechanism which leads to damage of the intestine would not be activated.

At this point, it cannot be proven that the later introduction of types of grain containing gluten into the diets of small children can prevent the coeliac condition. In the best case, the symptoms may be delayed, but they will just appear as soon as gluten is ingested with food.

At least a part of the immune system can be influenced by heredity, and the inheritance of the coeliac condition is very common among blood relatives. Close relatives (parents, children, brothers and sisters) have a ten percent incidence rate, and with identical twins the incidence is at least seventy percent.

At this point, there is no known cure through which a coeliac could once again eat foods containing gluten without damage to the intestinal mucous membrane. The only solution is a gluten-free diet.

In many cases of persons with autism, poor digestion of casein (milk protein) and of gluten, produce two opiates (substances with stupefying properties, just like heroine and morphine) which enter into the circulation and poison the nervous system. The presence of these two opiates can be revealed by a special analysis of the urine. At present, even though there have not been many case examples, the analysis proves positive in around two thirds of cases, and consequently, in some cases, a gluten and milk-free diet is adopted.

DH, also known as ”Duhring’s Disease”, is a particular variant of the coeliac condition that can also be cured by a strictly gluten-free diet. It is recognized by the red pustules and blisters that appear on the elbow, knee, buttocks, neck, shoulders, and in the lower back are. The rash is similar to that of herpes. The body reacts simultaneously in the intestinal area to gluten in the diet as with the coeliac condition.

There is no relationship between an allergy to grain and the celiac condition, even if the primary cause of each is the protein from grain. The basic mechanisms of the intolerances are different.

Under no circumstances. Even if no visible symptoms are evident, the reintroduction of foods containing gluten would once again cause damage to the intestinal mucous membrane and other organs. And it would cause more or less the same problems to appear as at the onset of the coeliac condition.

No, because if the gluten-free diet contains everything a balanced diet should, then there is no shortage of any nutrient. The diet can sometimes be poor in vegetal fibre, and in this case it is good to favour the intake of vegetables, fruit and pulses.