So it’s been a while since your coeliac disease diagnosis. You’ve been sticking rigidly to your gluten-free diet and your symptoms are resolving. You’re starting to feel better. And no doubt, like the rest of us, you assume that your strict dietary adherence will turn your health around. You expect that your nutritional status will improve and that the existing damage to your intestine will heal. You hope that your gluten-free diet will prevent further intestinal damage and that ultimately this sacrifice will ward off the long-term complications of coeliac disease. But are you actually getting better? Are you healing?
Coeliac disease is an inflammatory autoimmune disease of the small intestine triggered by the ingestion of gluten in genetically susceptible individuals. The symptoms of coeliac disease vary greatly from gastrointestinal issues to neurological symptoms and conditions of malabsorption and malnutrition. Currently, the only effective treatment for coeliac disease is lifelong banishment of gluten from the diet. But is that enough?
Research suggests that despite strict dietary compliance, complete healing of intestinal lesions caused by coeliac disease is rarely achieved. For most people, a variable degree of inflammation persists in their small intestine.
Research in Italy (1) found that only 8% of coeliacs diagnosed as adults completely recover or reach ‘histological normality’ after 16 months on a gluten-free diet. While 73% of the coeliacs studied during this research (1) did respond positively to a gluten-free diet, the vast majority (65%) only achieved remission ‘with persistent epithelial lymphocytosis’. This means that while the structure of the villi recovered, the coeliacs still had inflammation within the intestinal mucosa. The underlying damage to their intestine hadn’t completely healed. Persistent inflammation of the intestinal mucosa is associated with an increased risk of severe complications in coeliac disease patients, even in the absence of symptoms (2).
So is there any point continuing with your strict gluten-free diet? Absolutely there is. The removal of gluten from your diet is critical to the treatment of coeliac disease in that it helps alleviate symptoms and normalise antibodies (3,4). However, a gluten-free diet is only the first step in your healing.
How do you know whether or not you are one of the rare cases that has healed completely? A follow-up intestinal biopsy is required. Blood tests normalise after the elimination of dietary gluten (5) and are useful in monitoring how well you are sticking to your gluten-free diet but they give no indication as to whether or not your intestinal damage is healing.
In the absence of a follow-up biopsy, you should assume that you do indeed have ongoing intestinal inflammation. And having made that assumption, you need to look beyond your gluten-free regime and make further changes to your diet and lifestyle to mitigate the health risks associated with inflammation.
Next time we’ll look at possible reasons why there is ongoing inflammation in your intestinal mucosa. Stay tuned!
- Lanzini, A., Lanzarotto, F., Villanacci, V., Mora, A., Bertolazzi, S., Turini, D., Carella, G., Malagoli, A., Ferrantes, G., Cesana, B.M., Ricci, C. (2009) Complete recovery of intestinal mucosa occurs very rarely in adult coeliac patients despite adherence to gluten-free diet, Alimentary Pharmacology and Therapeutics, 29: 1299-1308.
- Kaukinen, K., Peräaho, M., Lindfors, K., Partanen, J., Woolley, N., Pikkarainen, P., Karvonen, A. L., Laasanen, T., Sievänen, H., Mäki, M., Collin, P. (2007) Persistent small bowel mucosal villous atrophy without symptoms in coeliac disease, Alimentary Pharmacology and Therapeutics, 25: 1237-1245.
- Rostom, A., Murray, J.A., Kagnoff, M.F. (2006) American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease, Gastroenterology, 131: 1981-2002.
- Haines, M.L., Anderson, R.P., Gibson, P.R. (2008) Systematic review: the evidence base for long-term management of coeliac disease, Alimentary Pharmacology and Therapeutics, 28: 1042-1066.
- Rostom, A., Dube, C., Cranney, A., Saloojee, N., Sy R., Garritty, C., Sampson, M., Zhang, L., Yazdi, F., Mamaladze, V., Pan, I., MacNeil, J., Mack, D., Patel, D., Moher, D. (2005) The diagnostic accuracy of serologic tests for celiac disease: a systematic review, Gastroenterology, 128: S38-46.