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Life StoryDec/Jan 2009 Issue

A Specialist on Celiac Disease

Living Without editor, Alicia Woodward, talks with Peter H.R. Green, MD, director of the Celiac Disease Center at Columbia University and author of Celiac Disease, A Hidden Epidemic (HarperCollins).

Living Without: You say that the human body did not evolve to fully digest wheat. Can you explain?

Dr. Green: Wheat has only been domesticated in the last 10,000 years. Our digestive systems can’t fully chop up gluten, the protein in wheat. We’re left with large molecules of up to 30 amino acids that can be absorbed into the intestinal lining (probably during gastrointestinal infections) and that interact with the immune system, causing celiac disease in genetically predisposed individuals. We evolved to eat meat. Our enzymes digest meat protein fully into single amino acids or molecules of 2 to 3 amino acids that are readily absorbed.

Peter H.R. Green, MD

Are you suggesting that everyone should limit gluten consumption?
No, not necessarily. But many people who don’t have celiac disease feel better not eating wheat and it may be because it’s poorly digested.

Celiac disease specialists say that people should not start the gluten-free diet without proper diagnosis. Why is getting a diagnosis so important?
You don’t know if you have celiac disease and require a strict gluten-free diet without getting a definitive diagnosis by antibody blood tests and/or a biopsy for small intestinal damage. If symptoms are present, it is better to have the diagnosis of celiac disease established with certainty.

Celiac disease is a potentially life-threatening disease that requires a life-long gluten-free diet. Individuals with celiac disease have increased risks of malignancies and autoimmune diseases that adhering to a strict gluten-free diet prevents. With a diagnosis, you know that your vitamin, mineral and bone density levels must be monitored and that you should have regular physical exams to check for malignancies. You also know that family members should be tested for the disease every three to five years.

Some people may feel better on a gluten-free diet. If they don’t test positive for celiac disease, they may still be gluten sensitive. They may feel better by avoiding gluten, or just wheat. They may not need as strict a gluten-free diet, just limited.

Is the line between celiac disease and gluten sensitivity kind of fuzzy?
In a way. Celiac disease and gluten sensitivity are distinct conditions. But we don’t yet have a mechanism to explain gluten sensitivity. We can’t define it. However, a classic example of gluten sensitivity is dermatitis herpitiformis (DH), skin lesions that are part of celiac disease. If you have DH, you’ve got celiac disease. Yet 20 percent of people with DH have a totally normal intestinal biopsy.

You’ve said that people with untreated celiac disease have increased risk of mental health conditions. This isn’t well known in the mental health community, is it?
Emotional problems, such as depression, anxiety, attention deficit/hyperactivity disorder and even schizophrenia, are more common in celiac disease but American doctors don’t know much about the relationship with celiac disease. The standard of care in America is that many doctors still don’t know much about this condition. Diagnosing it is easy. The challenge is getting doctors to think about it. And what influences doctors is medical research. Patients and doctors have to get with the program.

Get with the program?
Most national organizations for people with chronic diseases raise money for research. But it’s not in the culture of people with celiac disease to raise money for celiac disease research or to support the Celiac Disease Centers.

Why is that?
Because they’re just interested in finding what to eat. The national celiac support groups have been telling people what to eat. But there is a lot of needed research and many questions to be answered about this disease. Raising money for research is the way to make doctors more aware of the disease.

Peter H.R. Green, MD, is attending physician at the Columbia University Medical Center and professor of clinical medicine at the College of Physicians and Surgeons, Columbia University. For more information about the Celiac Disease Center at Columbia University, go to www.celiacdiseasecenter.columbia.edu. LW

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