Know thy enemy, celiac sufferers

Jennifer Sygo, National Post 

Know thy enemy, celiac sufferers

Cornerstone of the Western diet, wheat is anathema to celiac sufferers, many of whom remain undiagnosed

David Silverman / Getty Images / National Post

Imagine you are a thirtysomething woman, with a family, a career and a busy lifestyle. Despite your best efforts to eat well and be active, you constantly feel run down. At your annual physical, your doctor mentions that your iron is low, a condition not uncommon for a woman your age, so you pop some iron pills and pledge to make roast beef for dinner this Sunday. You suffer from migraine headaches from time to time, and you’ve had a long-standing battle with bloating and constipation, but you tell yourself that stress, hormones and eating on the run are probably the culprits.

Depending on how in-depth your discussions are with your physician, it’s possible that you could go for years without making the connection between these seemingly random symptoms. Yet with a bit of investigation, you might find out that you suffer from an increasingly diagnosed illness that has serious consequences: celiac disease.

In the first of a two-part series, we’ll examine the basics of celiac disease, including the symptoms and diagnosis. Next week, we’ll look at gluten-free diets, the cornerstone treatment for celiac disease, but also an increasingly popular — and controversial — lifestyle choice.


Put simply, celiac disease is an autoimmune response to gluten, a protein found in wheat, barley and rye grains, as well as their byproducts. Also known as gluten-sensitive enteropathy, celiac disease is thought to affect a little more than 1% of Canadians, yet current estimates are that the vast majority of cases (up to 97%) are yet to be diagnosed.

Physiologically, consumption of gluten by someone with celiac disease causes damage to a part of the small intestine known as the villi. Put simply, these villi are tiny, finger-like protrusions of the intestinal wall whose purpose is to increase the surface area of the bowel, allowing the food we eat to be fully broken down and the nutrients absorbed. Without properly functioning villi, celiac sufferers are limited in their ability absorb an array of essential nutrients, including iron, calcium, and B vitamins, and the long-term consequences can be severe: Iron deficiency anemia and bone loss (potentially leading to osteoporosis) are two of the manifestations of these nutrient deficiencies, but there are many others.


Celiac disease, which can occur at any age, usually presents first and foremost as digestive issues, in particular diarrhea, constipation, gas and bloating, or even a combination. The damage to the villi also means a lack of enzymes critical to digestion, which contribute to even more symptoms; for example, celiac disease and lactose intolerance often go hand-in-hand.

Beyond digestive issues, however, celiac disease is often associated with numerous other symptoms, including migraine headaches, easy bruising, extreme fatigue, depression and even infertility. Celiac disease can also present as a condition known as dermatitis herpetiformis, a sort of itchy rash that occurs all over the body, usually in the elbows, scalp, buttocks or knees.

While some celiac patients have symptoms that can have a pronounced effect on quality of life, many can have more subtle symptoms. For example, according to Shelley Case, registered dietitian and the author of Gluten-Free Diet: A Comprehensive Resource Guide, it’s estimated that up to 65% of cases show up only as iron deficiency or anemia. The result is that many individuals suffer far too long with the condition without proper diagnosis, while some are misdiagnosed with chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome (IBS), or even simple lactose intolerance. The longer a celiac sufferer is exposed to gluten, however, the more serious the consequences: Those with celiac are significantly more likely to develop bowel cancer in their lifetimes, and the side-effects of the nutrient deficiencies become more serious over time.


If celiac disease is suspected, blood tests for IgA tissue transglutaminase (tTG) or IgA endomysial (EMA) antibodies are often conducted. While the tests are common screening tools, they may still miss up to 10% of celiac cases. More recently, home-testing kits have become available (Canada Biocard provides a home test kit that measures tTG antibodies), but the testing still has the same limitations as traditional blood work.

The only definitive test is a small bowel biopsy, but according to Case, even it can be an imperfect diagnostic tool, partially because of variations in clinical expertise of those administering the test and interpreting the results, but also because patients often initiate a gluten-free diet before having the biopsy, which can cause the gut to heal, resulting in a negative test. Nonetheless, Case stresses the importance of being persistent until a diagnosis is reached: “Ultimately, it’s a diet for life, it’s a tough one, and it’s expensive,” she notes. Moreover, because celiac typically occurs in 10-15% of first-degree relatives, it’s important for those with the disease to have a firm diagnosis.


