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Coeliac Disease

Also indexed as: Coeliac Sprue, Non-Tropical Sprue

The gluten found in grain may trigger coeliac disease in some people. By keeping a close eye on your diet, you can remedy many of the symptoms. According to research or other evidence, the following self-care steps may be helpful:

Mix in a multivitamin
Take a daily high potency multivitamin that will supply your body with all the essential micronutrients, especially iron, vitamin D, vitamin K, calcium, magnesium, folic acid, and zinc

Breast-feed your baby
Reduce your newborn’s risk of developing coeliac disease by breast-feeding for more than a month

Go gluten-free
Work with a knowledgeable health professional to find out which gluten-filled foods should be avoided

Get routine check-ups
Have your doctor monitor your bone health, check for anaemia, and make sure you are not developing nutritional deficiencies

These recommendations are not comprehensive and are not intended to replace the advice of your doctor or chemist. Continue reading the full coeliac disease article for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and lifestyle changes that may be helpful.

About coeliac disease

Coeliac disease (also called gluten enteropathy) is an intestinal disorder that results from an abnormal immunological reaction to gluten, a protein found in wheat, barley, rye, and, to a lesser extent, oats.

In addition to damaging the lining of the small intestine, coeliac disease can sometimes affect other parts of the body, such as the pancreas (increasing the risk of diabetes), the thyroid gland (increasing the risk of thyroid disease), and the nervous system (increasing the risk of peripheral neuropathies and other neurological disorders). Occasionally, such damage occurs only in one or more of these parts of the body in the absence of damage to the intestines.

Product ratings for coeliac disease

Science Ratings

Nutritional Supplements

Herbs

Calcium (for deficiency only)

Enzymes

Folic acid (for deficiency only)

Iron (for deficiency only)

Magnesium (for deficiency only)

Multivitamin-mineral

Vitamin A (for deficiency only)

Vitamin D (for deficiency only)

Vitamin K (for deficiency only)

Zinc (for deficiency only)

Lipase

Vitamin B6 (for depression unresponsive to a gluten-free diet)

Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars

Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star

For a herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms?

Coeliac disease may not cause symptoms in some people. However, others may have a history of frequent diarrhoea; pale, foul-smelling, bulky stools; abdominal pain, wind, and bloating; weight loss; fatigue; mouth ulcers; muscle cramps; delayed growth or short stature; bone and joint pain; seizures; painful skin rash; or infertility. Microscopic examination of the small-intestinal lining reveals severe damage, especially in the jejunum (the central portion of the small intestines). People with untreated coeliac disease may eventually experience malaise and weight loss and have an increased risk of developing anaemia, osteoporosis, osteomalacia, and certain types of cancer. In addition to physical symptoms, some people may experience emotional disturbances, including feelings of anxiety and depression.

Dietary changes that may be helpful

All doctors agree that consumption of the gluten-containing grains wheat, barley, and rye must be avoided in all coeliac patients. Less consensus exists regarding the advisability of eating or restricting oats and oat products. While oats contain a substance similar to gluten, modern research suggests that eating moderate amounts of oats does not cause problems for most people with coeliac disease.¹ ² In one of these reports, approximately 95% of people with coeliac disease tolerated 50 grams (almost two ounces) of oats per day for up to 12 months.³

Strict avoidance of wheat, barley, and rye, and of foods containing ingredients derived from these grains, usually results in an improvement in gastro-intestinal symptoms within a few weeks, although in some cases the improvement may take many months. Tests of absorptive function usually improve after a few months on a gluten-free diet.⁴

Many people with coeliac disease become symptom-free when following gluten-free diets. Others, however, continue to experience symptoms, often resulting from the presence of trace amounts of gluten either permitted in some gluten-free diets or consumed by mistake. Such mistakes are easy to make because many processed foods contain small amounts of gluten. For people with residual symptoms, a diet that truly eliminates all gluten, followed by open and double-blind challenges, resulted in symptomatic improvement in 77% of those studied.⁵ A careful dietary analysis should ensure that all trace amounts of gluten are removed from the diet. If this fails to relieve symptoms after three months, then other food intolerances should be ruled out using an elimination diet.

Avoiding gluten may also reduce cancer risk. In one trial, 210 people with coeliac disease were observed for 11 years. Those who followed a gluten-free diet had an incidence of cancer similar to that in the general population. However, those eating only a gluten-reduced diet or consuming a normal diet had an increased risk of developing cancer (mainly lymphomas and cancers of the mouth, pharynx, and oesophagus).⁶

Children with untreated coeliac disease have been reported to have abnormally low bone mineral density. However, after approximately one year on a gluten-free diet, bone mineral density increased rapidly and approximated the level seen in healthy children.⁷ Long-term adherence to a gluten-free diet ensures normal bone density and is an important preventive measure in young people with coeliac disease.⁸

Adults with coeliac disease also have significantly lower bone mineral density than do healthy adults. After consumption of a gluten-free diet for one year, bone mineral density of the hip and lumbar spine has been reported to increase by an average of more than 15%.⁹

Infertility, which is common among people with coeliac disease, has been reportedly reversed in both men and women after commencement of a gluten-free diet.¹⁰

Some people with coeliac disease may be intolerant to other foods, in addition to gluten. Foods that have been reported to trigger symptoms include cows’milk¹¹ and soya.¹² ¹³ ¹⁴

Lifestyle changes that may be helpful

In one study, children who were breast-fed for less than 30 days were four times more likely to develop coeliac disease, compared with children who were breast-fed for more than 30 days.¹⁵ Although this study does not prove that breast-feeding prevents the development of coeliac disease, it is consistent with other research showing that breast-feeding promotes a healthier gastro-intestinal tract than does formula-feeding.¹⁶

Other therapies

Strict adherence to a gluten-free diet is essential, although doctors are questioning the need for all coeliac patients to avoid oats. People with severe damage to intestinal tissue may be prescribed intravenous nutritional supplements in order to replace unabsorbed nutrients.

Vitamins that may be helpful

The malabsorption that occurs in coeliac disease can lead to multiple nutritional deficiencies. The most common nutritional problems in people with coeliac disease include deficiencies of essential fatty acids, iron, vitamin D, vitamin K, calcium, magnesium, and folic acid.¹⁷ Zinc malabsorption also occurs frequently in coeliac disease¹⁸ and may result in zinc deficiency, even in people who are otherwise in remission.¹⁹ People with newly diagnosed coeliac disease should be assessed for nutritional deficiencies by a doctor. Coeliac patients who have not yet completely recovered should supplement with a high-potency multivitamin-mineral. Some patients may require even higher amounts of some of these vitamins and minerals—an issue that should be discussed with their doctor. Evidence of a nutrient deficiency in a coeliac patient is a clear indication for supplementation with that nutrient.

After commencement of a gluten-free diet, overall nutritional status gradually improves. However, deficiencies of some nutrients may persist, even in people who are strictly avoiding gluten. For example, magnesium deficiency was found in 8 of 23 adults with coeliac disease who had been following a gluten-free diet and were symptom-free. When these adults were supplemented with magnesium for two years, their bone mineral density increased significantly.²⁰

In another study, six people with diet-treated coeliac disease had abnormal dark-adaptation tests (indicative of “night blindness”), even though some were taking a multivitamin that contained vitamin A. Some of these people showed an improvement in dark adaptation after receiving larger amounts of vitamin A, either orally or by injection.²¹ People with coeliac disease should discuss the possibility of vitamin A deficiency with a doctor before taking vitamin A supplements.

Malabsorption-induced depletion of vitamin D can lead to osteomalacia (defective bone mineralization) in people with coeliac disease.²² Although supplementation with vitamin D appears to increase bone density, the excess risk of bone fracture may not be entirely eliminated.

It is possible that subtle deficiencies of other nutrients may exist in people with coeliac disease who are on a gluten-free diet and are in remission. People who are not strictly avoiding gluten are likely to have more severe deficiencies. Because of the complexity of this condition and the multiple nutritional factors involved, people with coeliac disease should be under the care of a doctor. Some doctors may recommend use of nutritional supplements, including a high-potency multivitamin-mineral supplement, to reduce the risk of future deficiencies. No controlled trials have investigated the value of supplements in the minority of coeliac disease patients who do not go into remission in response to a gluten-free diet.²³

In one trial, 11 people with coeliac disease suffered from persistent depression despite being on a gluten-free diet for more than two years. However, after supplementation with vitamin B6 (80 mg per day) for six months, the depression disappeared.²⁴

People with coeliac disease often do not produce adequate digestive secretions from the pancreas, including lipase enzymes²⁵ In a double-blind trial, children with coeliac disease who received a pancreatic enzyme supplement along with a gluten-free diet gained significantly more weight in the first month than those treated with only a gluten-free diet.²⁶ However, this benefit disappeared in the second month, suggesting enzyme supplements may only be useful at the beginning of dietary treatment.

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

References
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1. Srinivassan U, Leonard N, Jones E, et al. Absence of oats toxicity in adult coeliac disease. BMJ 1996;313:1300–1.

2. Kemppainen TA, Heikkinen MT, Ristikankare MK, et al. Unkilned and large amounts of oats in the coeliac disease diet: a randomized, controlled study. Scand J Gastroenterol 2008;43:1094–101.

3. Jantauinen EK, Pikkarainen PH, Kemppainen TA, et al. A comparison of diets with and without oats in adults with celiac disease. N Engl J Med 1995;333:1033–7.

4. Greenberger JN, Isselbacher KJ. Disorders of absorption. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill, 1998, chapter 285.

5. Faulkner-Hogg KB, Selby WS, Loblay RH. Dietary analysis in symptomatic patients with coeliac disease on a gluten-free diet: the role of trace amounts of gluten and non-gluten food intolerances. Scand J Gastroenterol 1999;34:784–9.

6. Holmes GKT, Prior P, Lane MR, et al. Malignancy in coeliac disease—effect of a gluten free diet. Gut 1989;30:333–8.

7. Mora S, Barera G, Ricotti A, et al. Reversal of low bone density with a gluten-free diet in children and adolescents with celiac disease. Am J Clin Nutr 1998;67:477–81.

8. Mora S, Barera G, Beccio S, et al. Bone density and bone metabolism are normal after long-term gluten-free diet in young celiac patients. Am J Gastroenterol 1999;94:398–403.

9. McFarlane XA, Bhalla AK, Robertson DAF. Effect of a gluten free diet on osteopenia in adults with newly diagnosed coeliac disease. Gut 1996;39:180–4.

10. Baker PG, Read AE. Reversible infertility in male coeliac patients. BMJ 1975;2:316–7.

11. Sewell P, Cooke WT, Cox EV, Meynell MJ. Milk intolerance in gastrointestinal disorders. Lancet 1963;2:1132–5.

12. Haeney MR, Goodwin BJF, Barratt MEJ, et al. Soya protein antibodies in man: their occurrence and possible relevance in coeliac disease. J Clin Pathol 1982;35:319–22.

13. Mike N, Haeney M, Asquith P. Soya protein hypersensitivity in coeliac disease: evidence for cell mediated immunity. Gut 1983;24:A990.

14. Ament ME, Rubin CE. Soy protein—another cause of the flat intestinal lesion. Gastroenterology 1972;62:227–34.

15. Auricchio S, Follo D, de Ritis G, et al. Does breast feeding protect against the development of clinical symptoms of celiac disease in children? J Pediatr Gastroenterol Nutr 1983;2:428–33.

16. Udall JN, Colony P, Fritze L, et al. Development of gastrointestinal mucosal barrier. II. The effect of natural versus artificial feeding on intestinal permeability to macromolecules. Pediatr Res 1981;15:245–9.

17. Connon JJ. Celiac disease. In: Shils ME, Olson JA, Shike M, eds. Modern Nutrition in Health and Disease, 8th ed. Philadelphia: Lea & Febiger, 1994, 1062.

18. Crofton RW, Glover SC, Ewen SWB, et al. Zinc absorption in celiac disease and dermatitis herpetiformis: a test of small intestinal function. Am J Clin Nutr 1983;38:706–12.

19. Solomons NW, Rosenberg IH, Sandstead HH. Zinc nutrition in celiac sprue. Am J Clin Nutr 1976;29:371–5.

20. Rude RK, Olerich M. Magnesium deficiency: possible role in osteoporosis associated with gluten-sensitive enteropathy. Osteoporos Int 1996;6:453–61.

21. Russell RM, Smith VC, Multak R, et al. Dark-adaptation testing for diagnosis of subclinical vitamin-A deficiency and evaluation of therapy. Lancet 1973;2:1161–4.

22. Basha B, Rao S, Han ZH, Parfitt, AM. Osteomalacia due to vitamin D depletion: neglected consequence of intestinal malabsorption. Am J Med 2000;108(4):296–300.

23. O’Mahony S, Howdle PD, Losowsky MS. Review article: management of patients with non-responsive coeliac disease. Aliment Pharmacol Ther 1996;10:671–80 [review].

24. Hallert C, Astrom J, Walan A. Reversal of psychopathology in adult celiac disease with the aid of pyridoxine (vitamin B6). Scand J Gastroenterol 1983;18:299–304.

25. Patel RS, Johlin FC Jr, Murray JA. Celiac disease and recurrent pancreatitis. Gastrointest Endosc 1999;50:823–7.

26. Carroccio A, Iacono G, Montalto G, et al. Pancreatic enzyme therapy in childhood celiac disease. A double-blind prospective randomized study. Dig Dis Sci 1995;40:2555–60.

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The information presented in Aisle7 is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or chemist for any health problem and before using any supplements or before making any changes in prescribed medications.