Celiac Update From Local GI Doc

Bonnie - Dr. Semrad definitely understands the nuances of the celiac issue. While I agree with her that self-diagnosing a gluten issue is a big mistake, I believe there are other reasons to avoid wheat other than just gluten.

Courtesy of Medill Reports Chicago

Gut problems - you’re not alone
by Tavaner K. Bushman

Studying the digestive system may not have the glamor or glory of other fields of medicine, but with an increasing number of Americans with digestive problems, it is essential. Dr. Carol Semrad, a gastroenterologist and associate professor of medicine at the University of Chicago, finished her medical degree at Columbia University in 1982, a time when fewer women were in medicine. She specializes in celiac disease, an autoimmune and digestive disease triggered by eating gluten, a protein found in wheat, barley and rye. She also has a background in clinical nutrition.

How did you become interested gastroenterology?

In medical school I liked internal medicine. I thought it was mentally the most challenging and comprehensive study of disease. If you knew the pathophysiology of how disease presents, anything else like surgery, was more mechanical. I was more interested in primary-disease processes.

I was very interested in the public health issues of food contamination and infectious diseases. Gastroenterology and the small bowel, where nutrition occurs and much of what goes on with digestion and absorption.

And celiac disease?

Celiac disease, although it was known in Europe, England and Ireland, in the U.S. it was viewed as a rare disease. When I trained in gastroenterology in the '80s, we would become excited if we saw a case of it once in a year. It wasn’t studied much.

Fast forward into the ‘90s when we developed antibody tests that were specific to identifying the disease and began to screen the American population and saw that there was a very high prevalence for the disease.

As relative to my colleagues in gastroenterology, I had been working in the area of small bowel disease, and it was the perfect opportunity for me to step in and take on celiac disease because I knew it well, but hadn’t seen it often.

Has the recent press coverage on celiac had an adverse affect with people self-diagnosing?

Yes, it has. I don’t blame anyone for wanting to know what is wrong with them, but there is a lot of good information and bad information on the Internet. Once individuals say, ‘Oh, I have this. I will just stop eating wheat,’ they lose the opportunity to make a secure diagnosis.

Then they get partially better or later realize that living gluten-free is a lot of work, more expensive and socially a lot more difficult than they thought and they want to know if they really have the disease. It’s hard to go backward and diagnose celiac once someone has been gluten-free. Triggering the disease is not always as easy as we thought it would be.

Is celiac considered a digestive disease?

Yes. I know it is always written about as an autoimmune disease, but I am very careful about using the word ‘autoimmune’ because we know that it is triggered by the gluten molecule. It is not that the self is attacking itself randomly. We know that there is the outside trigger and if you take it away, for 90 percent of people their bowel calms down. If you take the gluten away the lining regrows, which is a beautiful thing because there are very few diseases where you take something away and people get better.

It is true that if untreated, we don’t really know how the other autoimmune attacks occur. In other words, why is the thyroid attacked resulting in thyroiditis or Type 1 diabetes? We don’t know the exact connection that leads to autoimmune self damage.

In regards to celiac disease, what is your research currently focusing on?

We know gluten triggers the disease, but we don’t know what the most important steps of the inflammatory process are. There is a subset of people who don’t get 100 percent better when they take gluten away or they have a lot of trouble staying away from gluten. We believe we need other modalities to treat as an adjunct to the gluten-free diet.

We are also doing a survey to look at screening rates in first-degree relatives of [celiac patients] to try to determine factors or barriers that stop first-degree family members from being screened. This will be important in terms of diagnosing the disease and getting to as many people as we can.

What are some of the biggest misconceptions about celiac disease?

The biggest misconception that came out of our survey is that individuals without digestive symptoms think they don’t have the disease. They think, ‘If I don’t have a bellyache or some sort of digestive problem, I don’t have celiac disease.’ That is just not true.

The second is the genetic testing for celiac disease. There are two genes - we call them risk-associated alleles - which means that if you have of of those two gene types, you have the genetic capacity to have the disease. It doesn’t mean you are going to get the disease, it doesn’t mean you have the disease. It’s just a thumbprint of one of the genetic components that have to be there to order for you to get the disease.

It seems that more and more people are suffering from digestive ailments. Why is this?

I don’t know. In our clinics we see patient after patient complaining of sometimes just a bellyache or gas, bloating or discomfort. It is described in many different ways. Some times it’s celiac disease, some times it’s not.

I can’t tell if there is more complaint about digestion because people are more willing to acknowledge it, where before people would be quieter about their illnesses.

People are creatures of habit, and with technological advances there are no boundaries to people’s work and less stable eating habits. I think there is a big connection there between that kind of stress and the gut.

For people without celiac disease, is gluten really so bad?

We do have some evidence that humans don’t digest the gluten protein as well as rice and corn protein. We lack the enzymes to totally break the gluten protein into the basic two or three amino acids that are in general not toxic and can’t ever trigger the immune system. [Gluten] may be more of an irritating [protein in the] grain that we ever knew.

Of all the proteins in wheat, gluten is what makes foods chewy and elastic. Over the years, people have cultivated for that property, so there is more and more gluten in each grain of wheat than there was 2000 years ago. No one was ever exposed to the concentration of gluten that they are now.

We don’t know why the prevalence of celiac disease is going up. It is going up in all countries. We know something is going on, we just don’t know what.