CCA Publishes Management of Bone Health Paper

The Professional Advisory Council of the CCA has written a paper on bone health. It’s now been published and will become one of our standard resources. It’s also 6 pages long, so here are the key points.

  • Celiac disease (CD) is a chronic disorder that affects bone structure. It requires strict lifelong adherence to a gluten-free diet (GFD), and long-term monitoring of patients with CD should include assessment of bone health.
  • Bone health assessment in CD with malabsorption requires bone mineral density (BMD) testing at diagnosis. Correction of malabsorption of calcium, phosphate, and vitamin D should be ensured. At the time of diagnosis, patients should receive counselling on a GFD and on the nutrition required to restore bone health. Intake of calcium and vitamin D should be optimized using dietary sources, whenever possible. Patients should be encouraged to participate in weight-bearing exercises, limit alcohol intake, and avoid cigarette smoking.
  • Evidence for management of low BMD and prevention of fractures in CD is limited. Strict adherence to a GFD seems to be the only effective treatment to improve BMD in adults with CD and decrease the risk of fractures.

If you would like to read the whole paper, you can find it at http://www.cfp.ca/content/cfp/64/6/433.full.pdf

Non-Celiac Gluten Sensitivity: How to Diagnose and Differentiate it from Celiac Disease

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By the Canadian Celiac Association Professional Advisory Council

SUMMARY:

  • Non-Celiac Gluten Sensitivity can present with intestinal and extra-intestinal symptoms
  • There are no biomarkers for diagnosis
  • Autoantibodies (TTG, EMA, DGP) are absent
  • There is no villous atrophy
  • Diagnosis requires excluding celiac disease by serological tests
  • A gluten-free diet should not be started before ruling out celiac disease
  • The gluten-free diet is complicated and expensive
  • Patients should be referred to a dietitian with expertise in the gluten-free diet.

The spectrum of gluten-related disorders includes celiac disease, dermatitis Herpetiformis, gluten ataxia, wheat allergy and nonceliac gluten sensitivity. The term non-celiac gluten sensitivity (NCGS) is used to describe the clinical state of individuals who develop symptoms when they consume gluten containing foods and feel better on a gluten-free (GF) diet but do NOT have celiac disease.

Celiac Disease
Celiac disease is a multi-system autoimmune disorder that is triggered by ingestion of gluten (a protein in wheat, rye, and barley) in genetically susceptible individuals. A common disorder, affecting about 1% of the population, patients can present with a variety of intestinal and non-intestinal symptoms. Autoantibodies such a tissue transglutaminase antibody (TTG), endomysial antibody (EMA) and deamidated gliadin peptide (DGP) are produced in the body and form the basis of serological tests used for screening. The diagnosis of celiac disease is confirmed by a small intestinal biopsy and treatment consists of a strict GF diet for life. Adherence to the GF diet results in the resolution of symptoms and intestinal inflammation, with the autoantibodies becoming negative over time. Celiac disease is a serious disorder with patients being at risk for nutritional deficiencies and development of other autoimmune disorders and rarely malignancies such as small intestinal lymphoma.

Non-Celiac Gluten Sensitivity
Non-celiac gluten sensitivity is frequently a self-diagnosis; hence the true prevalence is difficult to establish. There are currently no biomarkers for this disorder. In a survey of 1,002 people from the United Kingdom, 13% reported having gluten sensitivity, with 3.7% claiming to be on a GF diet. In a large study from Italy of 12,255 individuals, NCGS was found to be only slightly more common than celiac disease. Data from the National Health and Nutrition Examination Survey in the United States found that 0.55 to 0.63% of people followed a GF diet in the absence of celiac disease. This prevalence is similar to that of combined diagnosed and undiagnosed cases of celiac disease. The symptoms of NCGS are highly variable. These include bloating, abdominal pain and diarrhea; symptoms mimicking irritable bowel syndrome. Other intestinal manifestations include nausea, acid reflux, mouth ulcers, and constipation. Individuals may have non-intestinal symptoms such as feeling generally unwell, fatigue, headaches, foggy mind, numbness, joint pains, or skin rash. An individual may have one or more symptoms.

The clinical symptoms of NCGS and celiac disease overlap making it difficult to distinguish the two disorders on the basis of symptoms alone. In one study of adults, patients with celiac disease were more likely to have a positive family history, personal history of other autoimmune disorders and nutrient deficiencies compared to those with NCGS. It is important to note that in NCGS, the TTG, EMA, and DGP antibodies are absent and there is no villous atrophy (damage to the small intestine) on biopsy. Therefore, the diagnosis of NCGS can only be established by excluding celiac disease.

Non-celiac gluten sensitivity was first reported in the 1970’s. However, over the last decade, an increasing number of people are following a GF diet for perceived health benefits. This has renewed both interest and concern whether these individuals have a true gluten-related disorder. There is a real possibility that some of those who go on a GF diet on their own could, in fact, have celiac disease. These individuals may not get diagnosed or receive adequate nutritional counseling from a dietitian and appropriate follow-up from their physicians. As a result, this may put them at risk for long-term complications of celiac disease. Since the small intestinal damage resolves and the TTG (and other antibodies) normalize after starting a GF diet, the true diagnosis of celiac disease becomes difficult to establish.

Most clinical trials investigating the phenomenon of gluten sensitivity gave study subjects gluten-containing grains such as wheat, rye, and barley in their diet rather than pure gluten. Therefore, it has been postulated that individuals with NCGS may be reacting to another component in wheat rather than gluten. FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are types of carbohydrates that some people cannot digest very well. The bacteria in the colon ferment these carbohydrates resulting in gas, bloating, abdominal pain and diarrhea.

Wheat, barley, and rye are high in FODMAP, which may be a contributing factor to these symptoms. Furthermore, wheat contains other proteins called amylase/trypsin inhibitors (ATI) that in laboratory studies have shown to cause intestinal inflammation.

The GF diet can be very challenging to follow, as it is complicated and expensive. In addition, there are concerns about the nutritional adequacy of GF products as they can be high in fat and sugar, and often low in fiber, iron and B vitamins. For these reasons, patients requiring a GF diet should be referred to a registered dietitian with expertise in this diet. Currently, a lot remains unknown about NCGS.What is its exact pathophysiology? Is the sensitivity/intolerance to gluten a dose-related phenomenon? Is it a transient or a permanent problem? Do some individuals outgrow this condition over time? Are there specific diagnostic tests that can confirm the diagnosis? Clearly, more research is needed to clarify these issues.

Take Home Message:
What is most important for the public and healthcare professionals to know is that the diagnosis of non-celiac gluten sensitivity should not be made without excluding celiac disease. A gluten-free diet should NOT be initiated without a proper clinical assessment that includes serological testing with IgA-tissue transglutaminase antibody while the individual is on a regular gluten-containing diet.

Primary author: Dr. Mohsin Rashid

REFERENCES:
(1). Lebwohl B, Ludvigsson JF, Green PHR. Celiac disease and non-celiac gluten sensitivity. BMJ 2015;351;h4347
(2). Volta U, Bardella MT, Calabro A et al. An Italian prospective multicenter survey on patients suspected of having non-celiac gluten sensitivity. BMC Medicine. 2014;12:85.
(3). Kabbani TA, Vanga RR, Leffler DA et al. Celiac disease or non-celiac gluten sensitivity? An approach to clinical differential diagnosis. Am J Gastroenterol. 2014;109;(5);741-6

What is the CCA Professional Advisory Council?

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As we approach the month of May each year, there is always an interesting debate about what to focus on for Celiac Awareness Month. This year was easy! We are highlighting two excellent new documents created by the CCA’s Professional Advisory Council (PAC) and designed to provide much-needed guidance to primary health providers:

  • Follow-up of Patients with Celiac Disease: this guide, for medical doctors, aims to ensure proper follow-up and care for a patient diagnosed with celiac disease
  • Non-Celiac Gluten Sensitivity: also for medical doctors, this document explains non-celiac gluten sensitivity and how to diagnose it and differentiate it from celiac disease

Do you know what the PAC is? It is an expert advisory body for the CCA comprised of medical doctors (both general practitioners and specialists), dietitians, and even a cereal scientist! Their role is to help ensure that the CCA remains the best source of quality, science-based factual information on celiac disease, gluten sensitivity, and the gluten-free diet. The combined knowledge and dedication of this group of professionals is absolutely critical to the CCA’s reputation as a reliable, invaluable resource. This is a volunteer role; they give their time to the cause out of the goodness of their hearts, and we truly appreciate it. Hats off to the PAC!

Watch for more news about Celiac Awareness Month shortly and you will soon find the new documents online at www.celiac.ca. Take a copy to your next medical appointment.

Hope spring is coming your way!

Anne-Wraggett-ccaAnne Wraggett
President, Canadian Celiac Association