The surprising association between celiac disease & other medical conditions.
After Erica Dermer was officially diagnosed with celiac disease in 2011, she adopted a gluten-free diet in order to heal her damaged gut. However, in the aftermath of that diagnosis, the 35-year-old Phoenix resident discovered she had other health challenges. She was diagnosed with hypothyroidism and irritable bowel syndrome, along with a moderate case of small intestinal bacterial overgrowth. This was in addition to several preexisting conditions—gastroparesis (slow or incomplete emptying of the stomach), Ehlers-Danlos Syndrome (a connective-tissue disorder), endometriosis, adenomyosis (a painful condition where endometrial tissue grows into the muscles of the uterus) and generalized anxiety disorder. What in the world was going on?
Are Dermer’s other health conditions linked to celiac disease? Very possibly. Research has found that people with celiac disease have a higher risk of developing other conditions, particularly autoimmune diseases.
For instance, it’s well known that celiac disease and type 1 diabetes are linked. Up to about 8 percent of people with type 1 diabetes are diagnosed with celiac disease, a significantly greater percentage than occurs in the general population. And patients diagnosed with celiac disease also are at greater risk of being diagnosed with type 1 diabetes. Another condition commonly linked to celiac disease is inflammatory bowel disease (IBD), which encompasses Crohn’s disease and ulcerative colitis; the prevalence of IBD is up to 10 times higher in people with celiac disease than in those without.
Recent research has revealed that the spectrum of diseases associated with celiac disease may be much wider than previously thought. A team of scientists analyzing a database of the electronic health records of 36 million people discovered potential links between celiac disease and a multitude of conditions as diverse as liver disease, Graves’ disease, Hashimoto’s thyroiditis, lupus, eosinophilic esophagitis, anxiety disorder, Down syndrome, psoriasis and autism. The study, yet unpublished, was presented at the World Congress of Gastroenterology 2017.
“One purpose of our study was to use this giant nationwide database to find those links,” says Daniel Karb, MD, a third-year resident at University Hospitals Case Medical Center in Cleveland. “It has the power to really find connections that aren’t otherwise obvious.”
Who knew that nearly 16 percent of people with celiac disease have pancreatitis, versus 0.7 percent of people without celiac disease? Or that nearly 29 percent of those with celiac disease also have arthritis compared with just 8.4 percent of non-celiacs?
The prevalence rate of other conditions is increased, as well: Almost 19 percent of people with celiac have migraine headaches, compared to just 4 percent of non-celiacs. And a whopping 36.8 percent of people with celiac disease suffer from gastroesophageal reflux disease, nearly three times the GERD rate of non-celiacs (13 percent).
Related Conditions Target Gut & Brain
Why do people with celiac disease have higher rates of so many other conditions, autoimmune and otherwise? Scientists agree that certain genes, such as HLA-DQ2, play a role in the development of celiac disease, and certain environmental factors may trigger the disorder. However, they aren’t yet sure what the exact mechanism is that causes celiac and other diseases to appear in tandem, or one after another.
“We did find a connection between celiac disease and all of these other conditions in that you have an increased likelihood of having these other diseases if you have celiac disease,” says Karb. “But our study did not attempt to postulate a cause.”
One theory about why celiac disease can lead to other autoimmune diseases has to do with permeability inside the body. According to Luis Rodrigo, MD, emeritus professor at the University of Oviedo in Spain, the gliadin protein in gluten can trigger a series of events that results in a higher risk of additional autoimmune conditions.
“The gliadin stimulates the liberation of zonulin (a protein) that opens the intercellular unions present in the small bowel epithelium,” he says. “[This] increas[es] the intestinal permeability, leading to the pass[age] of other substances through this route.” Increased permeability—like “leaky gut”—may trigger an inflammatory response that kicks off new gastrointestinal conditions. In addition, neurological conditions—like gluten ataxia, gluten neuropathy and gluten encephalopathy—may result from this increased permeability.
“The gliadin also produces an increased permeability of the blood-brain barrier that permits the pass[age] of several proteins into the brain that cause inflammatory changes in the central nervous system,” Rodrigo says.
Another theory is that once the immune system is stimulated by one autoimmune condition, it remains hypersensitive to other triggers that can cause additional autoimmune conditions.
“Our immune system needs to be able to go back to baseline,” said Bana Jabri, MD, PhD, director of research at the University of Chicago Celiac Disease Center and a professor at the University of Chicago who studies the mechanics of complex inflammatory diseases. Jabri says that researchers need to determine whether people with celiac disease have immune systems that are less resilient in general and predisposed to inflammation—in essence, whether they’re unable to go back to baseline once they’re stimulated.
More Than Gluten Free
A number of people with celiac disease, like David Vineyard, manage a variety of medical issues while they live a strictly gluten-free lifestyle. Vineyard knows that an overactive immune system can result in far more than just a celiac disease diagnosis, something that he received in 2013 after years of odd gastrointestinal and neurological symptoms. He also has gluten ataxia, a syndrome in which gluten attacks the cerebellum and causes damage to the central nervous system, resulting in loss of motor control.
Vineyard, the 28-year-old owner of a gluten-free bakery in Ennis, Texas, found that simply giving up gluten was certainly helpful—but it didn’t make him completely better. Since his celiac diagnosis, he learned he also has ulcerative colitis and pancreatic enzyme issues. In addition, he has multiple food intolerances. He cannot eat dairy, peanuts, corn, soy or red meat.
Sick for years, Vineyard saw multiple healthcare providers to try to figure out what was going on. “It seemed like there was always a new intolerance cropping up or an immune system quirk—like a riot/war in my body with collateral damage.”
Having grown up loving to cook, Vineyard opted to forge that passion and his dietary needs into a career of serving others with food intolerances.
“I took what I knew and slowly started learning gluten-free baking and cooking,” he says. “I needed to fund my new diet, so I started selling my homemade gluten-free baked goods at the local farmer’s market. I’ve been doing it ever since.” When his evolving health needs prompted him to drop starches and grains from his diet, he tweaked the ingredients in his baked goods accordingly.
Vineyard’s dream? He hopes one day to have a 100 percent gluten-free, paleo food truck.
Dealing with celiac disease can be challenging. Adding other medical conditions definitely makes it even more so. Yet learning about the increased risk of developing associated conditions can provide an instructive heads-up in addressing unresolved (and seemingly unrelated) symptoms, hopefully resulting in accurate diagnoses and treatment—and better overall health.
Health and medical writer Laurie Saloman, MS, is the parent of a young adult with celiac disease.