ResearchReviewAdvances in Celiac Disease and Gluten-Free Diet
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Clinical Presentation
Samuel Gee, MD, described the classical features of celiac disease in 1887 as diarrhea, lassitude, and failure to thrive (9). At that time, Gee believed regulation of food was the main part of the treatment and noted that the disease was not age-specific. In 1953, Willem Karel Dicke demonstrated in a controlled study, that wheat, rye, and barley triggered celiac disease, and that the condition could be reversed after their exclusion from the diet (10). The first accurate description of the
Prevalence
Much of the data on the prevalence of celiac disease has come from European countries, where celiac disease was previously thought to be more common than in other parts of the world. Recent studies (2, 3, 4, 5, 6, 7) have estimated that in the United States, celiac disease occurs in approximately 1% of the general population (Figure 1), which is similar to that reported in Europe (2, 5, 7). Recently, several authors have reported data on the prevalence of celiac disease in Asia (44, 45), the
Genetic Predisposition
Celiac disease is one of the most common genetically based diseases (3). Approximately 97% of individuals with celiac disease have genetic markers on chromosome 6p21, called class II human leukocyte antigen (HLA), specifically HLA-DQ2 and HLA-DQ8. However, up to 40% of the general population also carries these HLA haplotypes (19). Their presence is necessary for the development of celiac disease, but the absence of these alleles virtually excludes the diagnosis. HLA-DQ2 is expressed in >90% of
Pathogenesis
Under normal physiologic conditions, the intestinal epithelium, with its intact intercellular tight junctions, serves as the main barrier to the passage of macromolecules, such as gluten proteins. These proteins have been classified into two major solubility fractions, the gliadins and glutenins, both of which contain disease-activating peptides (50, 51). The alcohol-soluble fraction of gluten, prolamins (namely gliadins, glutenins, hordeins from barley, and secalins from rye), are rich in
Diagnosis
No single test exists that can definitively diagnose or exclude celiac disease in every individual (19). Serological testing, used as an initial noninvasive screen, is the first step in pursuing a diagnosis of celiac disease. Widely available serological tests used for detecting celiac disease include antigliadin antibodies, anti-endomysium antibodies (EmA) and anti-tTG antibodies (73). The most sensitive and specific tests are the EmA and anti-tTG (74); antigliadin antibodies tests are no
Treatment
Currently, the only scientifically proven treatment for celiac disease is strict lifelong adherence to a gluten-free diet. All foods and medications containing gluten from wheat, rye, and barley, and their derivatives (Figure 2) are eliminated, as even small quantities of gluten may be harmful. Complete removal of gluten from the diet in a patient with celiac disease will result in symptomatic, serologic, and histologic remission in the majority of patients (15, 81, 82). Growth and development
Eating Gluten-Free
When a patient begins to eat gluten-free, there is often much concern and confusion as to which foods are allowed and which are not. Many foods are gluten-free, such as milk, butter, and cheese; fresh, frozen or canned fruits and vegetables; fresh meats, fish, poultry, eggs, beans, seeds, nuts; corn, and rice. Gluten is predominantly present in breads, cereals, and pastas, but is, surprisingly, found in seasonings, sauces, marinades, soy sauce, soups, salad dressings, and conveniently packaged
Label Reading and the Designation of Gluten-Free
People with celiac disease must read all food labels to ensure the gluten-free status of a food item. This process has become easier since the enactment of the Food Allergen Labeling and Consumer Protection Act of 2004 (134). It requires that all food products manufactured after January 1, 2006, be clearly labeled to indicate the presence of any of the top eight food allergens (milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, soybeans, and wheat). This act has simplified label
Conclusion
Celiac disease is recognized as a common multisystemic disorder that may be diagnosed at any age. At this time, the gluten-free diet remains the only available treatment. The gluten-free diet is a complex and challenging diet, but recent advances in the food industry are making it easier to follow. With more patients being diagnosed, there is a greater need for health care professionals who are knowledgeable about celiac disease and the gluten-free diet. Expert dietitians are responsible for
M. Niewinski is a specialist in nutrition and medical dietetics in the Department of Pediatrics/Genetics at the University of Illinois at Chicago Medical Center and an adjunct clinical instructor in the Department of Kinesiology and Nutrition at the University of Illinois at Chicago.
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M. Niewinski is a specialist in nutrition and medical dietetics in the Department of Pediatrics/Genetics at the University of Illinois at Chicago Medical Center and an adjunct clinical instructor in the Department of Kinesiology and Nutrition at the University of Illinois at Chicago.