By Vikki Petersen, DC, CCN
What is your opinion about screening individuals for celiac disease?
In the European Journal of Gastroenterology & Hepatology, a study was published last month titled: “Is it time to screen for adult coeliac disease?” One of my favorite researchers, Dr. Hadjivassiliou, led a team from England for this study.
According to the World Health Organization, a disease should meet the following criteria for mass screening:
Early clinical detection is difficult
Condition is common
Screening tests are highly sensitive and specific
Effective treatment is available
Untreated disease can lead to complications1
As the study by Dr. Hadjivassiliou put it, to meet the principles of mass screening, a disease must be common, a significant health burden, detectable and treatable. The key lies in the early detection and alteration of the natural history of disease. Thus, the purpose of screening would be to accurately detect a disease for which you could alter its normal course.
The researchers pointed out that:
1. Celiac affects 1 in 100 people.
2. Despite this, patients frequently have delays in diagnosis or may remain undetected.
3. There is an associated morbidity and mortality, which can be effectively treated by means of a gluten-free diet.
Their summary was then: “For these reasons, coeliac disease has been suggested as appropriate for mass screening.” However, they also acknowledged that factors such as “overestimation of morbidity and mortality, poor adherence to treatment, and costs of service provision may argue against the time being right for mass screening.” Therefore, the article is “food for thought,” according to the researchers.
If you suffer from gluten sensitivity or celiac disease and your health has benefited from instituting a gluten-free diet, you’ll likely be pro-screening. If you are like most people with celiac disease, you suffered for years, during which time you saw many doctors before receiving your diagnosis. If all doctors were committed to screening, you would likely have received your diagnosis many years earlier, avoiding many health problems and suffering.
If you consider that in the U.S. we currently are diagnosing only 5% of our celiacs, you may again feel that instituting a screening procedure could only help to elevate those poor statistics.
Dr. Alessio Fasano from the University of Maryland, along with several fellow researchers, posted a study online in September 2010 titled “Natural History of Celiac Disease Autoimmunity in a USA Cohort Followed Since 1974.” In the study, Dr. Fasano stated, “During a 15 year period, celiac disease prevalence increased 2 –fold and a 5-fold overall increase has occurred in the U.S. since 1974 due to lost immunological tolerance to gluten in adulthood.” In other words, the “incidence of celiac disease in the U.S. since 1974 has doubled every 15 years,” Dr. Fasano stated. These findings aligned with an earlier Finnish study in 2008 that found the same increasing incidence in their country.
What does this tell us? Celiac disease is on the rise. Further, it increases with age. As Dr. Fasano stated, “You are not necessarily born with celiac disease.” That may not sound like an earth shattering statement, but believe me it is. We, as clinicians, are taught that a genetic disease , which celiac is, presents itself in childhood. And the corollary: if one didn’t have it in childhood, one would not be able to develop it in adulthood. Dr. Fasano’s statement negated this long held truth.
For me, it solved an ongoing question that I hadn’t been able to resolve. That was the fact that patients frequently said they had been very tolerant of gluten until a particular event occurred in their life. That event could have been giving birth to a child, a surgery, or a bad infection. But for these people, it was clear that there was a point that separated their gluten tolerance from their gluten intolerance.
Did you know that autoimmune disease is the third most common disease category in the U.S. behind heart disease and cancer? Interestingly, the increasing incidence of celiac disease follows the increasing incidence of autoimmune diseases as a whole. Celiac disease is an autoimmune disease, but there are at least 100 others and they too are on the rise.2
While we know heredity is a factor in autoimmune diseases, the rate of celiac disease is rising too fast to be explained by genetics alone. So, what are we left with as a causative factor? The environment. And according to Dr. Fasano, specifically the environment or health of the small intestine is the culprit in this story.
Celiac disease is an autoimmune disease, and where there’s one autoimmune disease, there is often more. We know that celiac disease is associated with type 1 diabetes, rheumatoid arthritis, multiple sclerosis and more.
Dr. Fasano’s research into the substance zonulin, which controls whether the small intestine is leaky or not, revealed a marked association between a leaky gut and the development of type 1 diabetes in genetically prone rats.3 In this particular study, a specific strain of rats developed diabetes 100% of the time. Dr. Fasano designed a drug that prevented a leaky gut from developing in these rats, and 2/3 of them did not develop the disease. Thus, it seems that the health of the small intestine is a factor in creating type 1 diabetes, and perhaps other autoimmune diseases as well.
In my clinic, we see some dramatic changes in our patients with autoimmune diseases by increasing the health of their small intestine. Gluten is typically a huge culprit in creating a leaky gut, and we typically find these autoimmune patients to also have celiac disease or gluten sensitivity.
I think we’ve brought up some valid reasons to screen:
1. Celiac affects 1% of the general population and can strike at any age.
2. Autoimmune disease affects 5-8% of the U.S. population. It’s increasing every year, and where there’s one, there are typically more.
3. We only diagnose 5% of our celiacs, leaving 95% left to suffer needlessly.
What reasons would make screening a bad idea?
1. Not having sensitive testing. There would be no point in screening if the tools were faulty. I personally believe that testing has improved quite dramatically this year, but it can get even better.
2. The cost of testing always needs to be a consideration. Would the cost of a screening test be offset by the money saved in preventing ill health? In my opinion, that answer is a resounding “Yes!” [Note: A celiac blood test can costs as little as $30, depending on insurance coverage.]
So, where do you stand on screening for celiac disease?
1. Fasano, A. Should we screen for celiac disease? BMJ 2009;339:b3592
2. Donna Jackson Nakazawa. The Autoimmune Epidemic.Touchstone: 2008.
3. Watts T, Berti I, Sapone A, Gerarduzzi T, Not T, Zielke R, Fasano A: Role of intestinal tight junction modulator zonulin in the pathogenesis of type1 diabetes in BB diabetic prone rats. Proc Natl Acad Sci U S A 102 : 2916 –2921,2005
About Dr. Vikki Petersen
Vikki Petersen, DC, CCN, is founder of the HealthNOW Medical Center in Sunnyvale, CA, and co-author of The Gluten Effect. Dr. Petersen has been published in national and international medical journals, newspapers and magazines for her cutting edge work in the field of gluten sensitivity. Her commitment to increase the awareness of gluten sensitivity nationally is well recognized. She has a been a featured speaker at the annual Gluten Sensitivity & Celiac Forum held in northern California. HealthNOW Medical Center is a destination clinic, treating patients from all over the country.