Celiac disease is a unique permanent autoimmune disorder where ingestion of gluten results in damage to the small intestine in some genetically predisposed individuals. It is unique because we know that gluten drives this auto-immune response. This results in multiple nutritional deficiencies and manifests itself in various ways.
There are more than 200 symptoms and causes of celiac disease, which include but are not limited to:
Gastrointestinal: Chronic diarrhoea or constipation, vomiting, foul-smelling stool, abdominal bloating/pain and failure to thrive.
Extraintestinal: Weight loss, short stature, iron deficiency anaemia, inability to concentrate, dermatitis herpetiformis, mouth ulcers, dental enamel defects, chronic liver disease, osteopenia, osteoporosis, migraines, tingling or numbness in hands or feet, delayed puberty, infertility and frequent miscarriages.
Many patients could have a mild disease or even be asymptomatic. A triad of conditions develops Celiac disease - genetic predisposition, gluten exposure, and an unidentified trigger. The trigger can get activated at any age, and hence this condition may manifest itself for the first time anytime from infancy to 90 years of age.
Like the other parts of the world, celiac disease affects 1% of our population, especially in North India, where wheat forms the staple diet. So far, it is being diagnosed more often in children. Some individuals are at a higher risk of developing celiac disease than others: relatives of individuals with celiac disease, people with other autoimmune conditions and genetic conditions.
The diagnosis of celiac disease is at a low rate at present. However, it will increase exponentially with improved awareness amongst the medical and patient community.
The diagnosis and treatment of celiac disease depend on signs and symptoms, blood tests, biopsy and a positive response to the gluten-free diet. tTG-IgA is the most commonly used screening blood test for this condition. Besides, the total serum IgA test is also necessary since the tTG test will not be accurate in IgA deficient people, so it needs other tests. Duodenal (intestinal) biopsy interpreted by an experienced pathologist is necessary for the diagnosis. It is important to note that gluten consumption for 8-12 weeks before testing is essential to obtain an accurate result on the biopsy. A positive response to the gluten-free diet confirms the diagnosis. Keep in mind that the tTG antibody is not capable enough to make or refute the diagnosis of Celiac disease.
Currently, the treatment for this condition is purely dietary – eliminating gluten ingestion for life. Gluten is a protein found in wheat, rye and barley. One bread crumb has 1000 times more gluten than permissible! Even an intake in small quantities is not allowed. Keep in mind that no part of the wheat grain is safe, and there is no known process to make this soluble protein less antigenic and safe for consumption for these individuals.
Oats are also considered unsafe for two reasons – one, it is often contaminated with wheat, and two, about 10% of individuals with celiac disease will not tolerate pure oats either. The intestine starts healing after gluten removal from the diet. The healing process may take a few months up to two years. However, the individual begins to feel better much sooner, usually within two weeks. There are visible improvements in symptoms, especially gastrointestinal symptoms, as the intestine starts to recover. The tTG count reduces, though it may take 1-2 years to normalise.
If undiagnosed or untreated, celiac disease can result in complications like anaemia, weakness, stunted growth, malnutrition, lack of stamina, liver disease, osteoporosis, infertility, and cancer. It can also promote the development of other autoimmune conditions. Likewise, even in small amounts, accidental or intentional ingestion of gluten may or may not result in immediate symptoms but can cause intestinal damage resulting in complications. Therefore, it is essential to adhere to a strict lifelong gluten-free diet and undergo the recommended follow-up consultation, including an annual tTG test, to understand if there is any significant ingestion of gluten taking place.
There are many nutrient-dense gluten-free grains like jowar (sorghum), bajra (pearl millet), rajgira (amaranth/ramdana), ragi (finger millet/nachni), makka (corn), kuttu (buckwheat) and rice. These are readily available in India that we use in our regional cuisines. In addition, the availability and usage of some of the inherently gluten-free items like dals, vegetables, nuts, seeds, and spices in our cooking, offer a wide variety of gluten-free food options. But the lack of accurate knowledge about the presence or absence of gluten in packaged food products and the lack of gluten-free dining out options remain primary areas of concern for most individuals with celiac disease in India.
We will endeavour to continuously interact with the industry to impress the need for gluten-free labelling, availability of packaged gluten-free products, and safe dining out options. Providing specialist support on a gluten-free diet to India's first gluten-free camp for children is our first initiative in this regard. Watch this space to learn more about our other initiatives.