Being diagnosed with celiac disease can bring both relief – for finally having an answer – and a whole new set of worries – “what do I do now?”
Learning how to navigate the grocery store, schools, parties, restaurants and venues can be a daunting task. Luckily, due to an increase in general awareness about celiac disease, there are many resources devoted to making gluten-free living easier for people.
So, perhaps you have been on the gluten free diet and it is going well. Perhaps, though, you are still experiencing symptoms and wondering why. Before we begin to uncover these varying causes and what we can do about them, let’s review how celiac disease impacts the digestive system and the consequences of those changes.
Functional changes to digestion in celiac disease
Celiac disease is an inherited, autoimmune disease whereby the immune system, upon exposure to gluten, attacks and destroys portions of the small intestine. The small intestine is responsible for the breakdown, absorption, transport and assimilation of nutrients. This destruction sets the stage for malnutrition and chronic inflammation and a large cascade of consequences.
The immune system, upon exposure to gluten, releases inflammatory molecules that create inflammation and perpetuate an inflammatory response that has local and body-wide effects. Locally, in the small intestine, inflammatory products damage the lining of the gut, and create microscopic gaps in the lining of the gut, making it more permeable. Leaky gut becomes established.
Gluten itself is also able to create these gaps and increase permeability of the gut lining. The increased permeability allows large molecules like partially digested food molecules, pathogens and environmental toxins to pass through into the bloodstream. This is why people with celiac disease often have additional food sensitivities.
The increased inflammatory chemical and immune complexes that are now circulating throughout the whole body can trigger other autoimmune conditions – through a phenomenon known as molecular mimicry – such as diabetes type 1, Hashimoto’s thyroiditis, autoimmune liver disease, rheumatoid arthritis, lupus, multiple sclerosis, Addison’s syndrome, Sjogren’s syndrome, Raynaud’s syndrome and complex pain syndromes such as fibromyalgia and chronic fatigue syndrome. This is why people who have one autoimmune disease often have another. Autoimmunity loves to run in packs.
The destruction of the lining of the intestine, leaky gut and increased inflammatory molecules all contribute to the malabsorption of nutrients and the malnutrition of those with celiac disease.
Malabsorption is responsible for most of the related conditions and complications of celiac disease, including (but not limited to): osteoporosis, anemia, ADHD, infertility, depression, neuropathy, dental enamel defects, skin conditions and even certain types of cancer.
Additionally, gastrointestinal symptoms worsen – more bloating, cramping and gas ensue, along with bowel changes such as increased diarrhea, constipation, or a combination of both. Other non-GI symptoms are common such as headache, migraine, fatigue, body aches, joint pain, acne, eczema, rashes, irritability, brain fog and a host of other, almost innumerable symptoms.
Between mounting inflammation and destruction of portions of the gut, dysbiosis of the gut flora begins to occur. Dysbiosis refers to an imbalance between good, beneficial bacteria and unfavorable or harmful bacteria and yeasts. Fast-growing pathogenic bacteria and yeast are able to compete for space and crowd out normal gut flora. Proper bacterial balance in the gut is crucial for both normal digestion and immune function.
Another major functional change in those with celiac disease is reduced output of digestive enzymes, acid, bile and other digestive factors. Through chronic malabsorption and malnutrition, the body is not adequately equipped to make these products to aid in digestion. As such, the body’s ability to break down proteins and carbohydrates and emulsify fats is greatly reduced, further contributing to maldigestion and malabsorption.
IgA is a non-inflammatory immune molecule that is first-line defense against viruses, bacteria and other pathogens we may consume or inhale. IgA is notoriously low in people with celiac disease. As such, these pathogens are not rendered harmless and those with celiac are more susceptible to food-borne illness and are more prone to frequent colds.
It is safe to say that the vast majority of people with celiac disease, especially those for whom it has taken years to get a diagnosis, are also looking at the functional consequences of: malnutrition, increased inflammation and dysfunctional immune response, leaky gut, dysbiosis, potential pathogenic infection and reduced digestive fire.
Why symptoms persist
So, now that we have an idea how celiac disease creates changes both locally in the small intestine and more broadly in the entire body, we can begin to tease out and understand why some people just don’t feel better after cutting out gluten.
In a perfect scenario, one would cut out gluten (which IS the cure for celiac disease, by the way), the intestine would heal itself and begin absorbing food perfectly again, the dysfunctional inflammatory response would cease, gut flora would be restored to normal, enzymatic and acid output would increase, concurrent conditions and symptoms would disappear, and it would be all good. Right?
Right. Yet, it is not the case for many. Too many people still experience symptoms with a gluten free diet and even sometimes with good biopsy results.
If you are still experiencing symptoms, it is very important for you to rule out reasons for them. A common reason that shouldn’t be discounted is that somewhere, somehow gluten is still being consumed. Read labels, check with the manufacturers of medications and cosmetic and household products to make sure they are gluten free.
If you have been diagnosed with celiac, it could be possible that you also have another autoimmune disease or syndrome that is associated with celiac but has not yet been diagnosed. Or, there could have be additional gut disorder that mimics the symptoms of celiac such as microscopic colitis, ulcerative colitis, Crohn’s disease or even irritable bowel syndrome (though celiac is often misdiagnosed as IBS).
Far more likely than the above-mentioned scenarios is that an underlying functional digestive problem remains. Low stomach acid, insufficient digestive enzymes and bile, bacterial or other pathogenic overgrowth and gut permeability with inflammation will often continue even in the absence of gluten, because these changes all support and feed off of one another.
Additional, transient food sensitivities are likely and prevalent. The most common foods that people develop sensitivity to are milk and dairy products, soy, corn and citrus. Additional sensitivities will continue to drive dysfunctional immune response, leaky gut and inflammation.
It may take a bit of time and detective work to root out any additional factors that may be present, and to heal a dysfunctional digestive system, but it is well worth the trouble.
Correcting functional digestive issues
When you have ruled out any additional or concurrent diseases and have assured yourself that you are not getting any hidden sources of gluten from your food, products or cross contamination, the next logical step is to begin a gut restoration program that will heal the gut, improve digestion and absorption and normalize immune function.
The general concept in correcting a functional digestive imbalance is to first remove from the diet and gut any food or pathogen that could be contributing to symptoms – in addition to gluten, of course. Think of dairy products, corn soy and citrus, but other foods to be avoided include refined sugar and carbohydrates, which decrease proper immune function and interrupt proper hormonal signaling. You can get an IgG food sensitivity test to determine additional sensitivities.
Artificial sweeteners can cause bloating in susceptible individuals. Processed foods are best kept to a minimum until symptoms are under control. It is best to focus on warm, easy to digest foods like cooked vegetables, soups and stews, lean protein and healthy.
It is important to note that many concurrent food sensitivities can be reversed once appropriate digestive and immunological function is restored.
If bacterial overgrowth is present, it would be appropriate to initiate antibiotic therapy, whether by natural or conventional means. Please note that if you do use a conventional antibiotic, a 3 month course of a high quality probiotics is recommended to help build up normal gut flora. Candida overgrowth and parasites are also a consideration. Dysbiosis and candida infection can be confirmed with a complete digestive stool analysis (CDSA) test. For more on Candida, click here.
After the removal of contributing foods and pathogens, the next step is to replace digestive aids that may have been lost or compromised. This includes acid, digestive enzymes and bile salts. Low stomach acid is highly prevalent in people with celiac disease and often needs to be temporarily replaced until the stomach begins making its own acid again. Do not take acid if you have an ulcer, make sure your ulcer is healed first. Enzymes act both as a digestive aid and also help quell inflammation.
It is vital to replenish the beneficial bacteria with a course of probiotic supplementation. Probiotics will help tone and quell dysfunctional immune response, absorb and assimilate nutrients, protect against pathogens and help regulate the bowel, in addition to dozens of other functions.
An oft-overlooked step of healing in people with celiac disease is the repair of the lining of the small intestine itself. As I said before, sometimes the removal of gluten alone is not enough, and the lining needs additional support and help to really close the deal.
Focused nutrient support for the structural integrity and physiological function of the lining of the small intestine should be initiated. There are many nutrients and plants that specifically aid in the restoration of the lining of the gut. Most notable is the amino acid glutamine, which is a preferential fuel source for the cells that line the gut. Other important players are zinc, B vitamins, omega-3 fatty acids and plants and vegetables that have a demulcent, slippery quality like okra, onions, slippery elm and licorice.
By completing a gut restoration program, you are not only helping to improve your symptoms, but you are treating the very underlying mechanisms which caused them. Tackling and eliminating the underlying causes provides true cure and optimal mental, emotional and physical wellness.