Celiac Disease Showing Up in Many Forms and at All Ages

It’s nice to see more emphasis and greater study put toward celiac research.
— Dr. Dale
By Janice Neumann

(Reuters Health) - A classical set of celiac disease symptoms no longer reflects the profile of most newly-diagnosed patients, according to a new study from Italy.

Instead, doctors should take other symptoms into account and consider the possibility of celiac disease, even when patients don't fit the old image of the condition, researchers say.

"It's been a gradual phenomenon since the 1970s that fewer people are presenting with the classical diarrhea and more with non-classical or silent presentation, both in adults and children," said Dr. Peter Green, who wasn't involved in the study.

"We don't actually know why one person has diarrhea and another presents with abdominal pain or osteoporosis," said Green, director of the Celiac Disease Center at Columbia University in New York.

Dr. Umberto Volta and his coauthors wrote November 18 online in the journal BMC Gastroenterology that just 15 years ago, celiac disease was still thought of mainly as a rare pediatric food intolerance, whose most common signs were diarrhea and intestinal damage.

Volta, a professor of medicine at the University of Bologna in Italy and vice president of the Ethical Committee at St. Orsola-Malpighi University Hospital, and colleauges looked at the celiac patients diagnosed over the course of 15 years at that hospital.

The study involved 770 patients, 599 of them female, diagnosed between 1998 and 2007. Nearly half were diagnosed during the first 10 years of the study period and the rest in the last five years, indicating a steep rise in rates of diagnosis.

Among all the patients, 610 people, or 79%, had symptoms when they were diagnosed. But most of their problems were not the typical diarrhea and weight loss, but rather "non-classical" issues like bloating, osteoporosis and anemia. Diarrhea was a symptom in just 27%.

Indeed, classical symptoms became less common over the years, decreasing from 47% of patients during the first 10 years to 13% in the last five. Meanwhile, other problems, as well as a lack of any significant related illness, increased by more than 86%.

"The most striking change in clinical presentation of celiac disease over time has been the decrease of diarrhea as the leading symptom and the progressive increase of other non-classical gastrointestinal symptoms (such as constipation, bloating and alternate bowel habits as well as gastro-esophageal reflux, nausea, vomiting and dyspepsia)," Volta said in an e-mail to Reuters Health.

"A high proportion of celiac disease patients did not show any gastrointestinal symptom, but they displayed extra-intestinal manifestations such as iron-deficiency anemia, unexplained osteoporosis, abnormalities of liver-function tests and recurrent miscarriages," he said.

The most common illness associated with celiac was thyroid disease. Only half the patients had severe intestinal damage.

In later years, more patients were diagnosed with blood tests. That may be one factor accounting for the changing pattern of typical symptoms, Volta said, because the patients were diagnosed earlier.

"The effects of gluten weren't as severe yet," Volta said. "The story of celiac disease has been radically changed by the discovery celiac disease-related antibodies, which identify plenty of unsuspected cases."

Green agreed that testing has vastly improved diagnosis of the disease. He said that in the UK, anyone with iron deficiency or migraine is tested for celiac disease.

While most celiac specialists understand the varied symptoms, other physicians might not, he said. Green pointed out that in the United States, only 17% of people with the disease are actually diagnosed.

"Anyone can have celiac disease, it's common and underdiagnosed," said Green. "The message we want to get out is if you think you've got celiac disease, don't just go on a gluten-free diet, test for it."

Volta said he hoped the study reminded doctors about the many problems that can signal celiac disease.

"I hope doctors keep in mind that celiac disease is a very frequent food intolerance, which should be investigated not only in patients with diarrhea and overt malabsorption, but also in people (with other symptoms)," Volta said.

"The treatment by gluten-free diet improves the quality of life in symptomatic patients and prevents complications in all celiac disease patients including those without symptoms," he said.


BMC Gastroenterol 2014.

7 Sneaky Reasons You're Bloated

As a stomach doctor, these are all true!  Also, I'd add "gluten" sensitivity as another major cause for bloating. -- Dr. Dale



The Huffington Post  | By Abigail Wise

It’s uncomfortable, gross and occasionally embarrassing, but bloating is something we all deal with at one point or another. Gassiness isn't just from gorging yourself at the last family meal. Bloating happens because your body can't break down gas, like it does the food you swallow. Sometimes even the digestive process itself creates gas right in your abdomen. If it's not released, air begins to build up in the stomach and intestines, which can make your belly feel like a balloon.

This type of abdominal discomfort can pop up at any time, last for hours and sometimes antacids and burping just don't quite do the trick. Can't seem to beat the bloat? Here are seven reasons that gas is gurgling in your gut.

You're stressed out.

When stress hits us hard, some of our bodies react by driving blood away from the usual digestive process, Dr. Anne Nedrow, M.D., told As a result, you could end up with bloating, constipation, diarrhea or a plain old stomachache.

While stress itself could be to blame for bloating, the nervous habits that many of us pick up when we're anxious could also be the culprits, according to the Mayo Clinic. We chew gum, down carbonated drinks or even gulp air when we're nervous or feeling anxious. All of these habits push extra air into the stomach, which the body can't digest. This abdominal side effect is yet another reason to practice yoga, go for a run or do whatever it takes to de-stress.

Your medication is bringing on the bloat. Medications can come with a long, and sometimes nasty, list of possible side effects, including bloating. Meds that contain lactulose or sorbitol, or the diabetes medicine acarbose, are especially common culprits.

You ate too much.

Is that lump more than a food baby from your last big meal? An uncomfortable bubble in your belly could be gas trapped from eating too much in one sitting. Overeating is one of the most common causes of bloating. Research published in the International Journal of Obesity found that if you're binge eating, you're even more likely to encounter gassiness.

You chow down at superspeed. Stop gulping down your grub. Eating too quickly or drinking through a straw can result in swallowing bubbles of air along with your meal.

Plus, insufficient chewing can reduce your body's ability to digest carbs, nutritionist Monica Reinagel, M.S., LDN, CNS, tells The Huffington Post. This can create gas in the intestines, which makes you feel uncomfortable. Even if you're starved after a long day at the office, force yourself to chew thoroughly and take small sips before you swallow. This will help eliminate the air pockets that bloat your belly.

You're dehydrated. Just like crash diets cause the body go into starvation mode and cling to fat, your body begins to retain fluid when it's dehydrated, Marilyn Glenville, nutritional therapist, told Good Housekeeping. If you feel like you're retaining fluid, that probably means it's time to drink some more. Avoid carbonated drinks, which will likely exacerbate your problem. Instead, reach for herbal tea or a good old glass of water.

You're eating gassy foods.

Some foods are notorious for causing gas, Reinagel tells HuffPost. Cabbage, broccoli, kale, apples and avocados have all been known to cause bloating. Eating too much salt can also cause water retention, which can leave you feeling puffy. Plus, downing lots of fiber -- especially from supplements -- without drinking enough water is a fast track to a gassy gut. If you know the foods you're intolerant of -- dairy if you're lactose intolerant, for instance -- those might also be good to steer clear of if you're trying to break the bloat.

You have a chronic medical condition. Many disorders cause bloating, including celiac disease, dumping syndrome and even ovarian cancer. Irritable bowel syndrome is one of the most common. IBS affects the large intestine and causes food to be forced through the intestines faster than it should be, often resulting in gas and diarrhea. If you just can't seem to reduce your bloating, visit your doctor. Symptoms of many disorders can improve dramatically as people learn to control their condition.


Friends, please come see me if you think you have celiac disease.  There's a whole healthy life ahead of you! I got you,

- Dr. Dale




Celiac Disease Linked to Almost Doubled Risk of CAD

Marlene Busko

March 29, 2014

WASHINGTON, DC — Compared with the general population, individuals with celiac disease were almost twice as likely to have CAD, according to a large retrospective study presented here today at the American College of Cardiology (ACC) 2014 Scientific Sessions [1]. Even patients younger than aged 65 years were at higher risk.

Celiac disease—a chronic inflammatory condition of the digestive system that can damage the small intestine—was also linked with a 1.4-fold greater risk of stroke.

The study highlights a specific patient population that might be at higher risk of CAD, even in the absence of traditional CV risk factors, said coinvestigator Dr Rama Dilip Gajulapalli (Cleveland Clinic, OH). "Primary-care physicians, gastroenterologists, and [other] healthcare practitioners need to be mindful of their celiac patients; they have to be on the watch for probable cardiac diseases," he said during a press briefing.

The possible mechanism for the heightened risk may be related to chronic inflammation. "People with celiac disease have some persistent low-grade inflammation in the gut that can spill immune mediators into the bloodstream, which can then accelerate the process of atherosclerosis and, in turn, CAD," Gajulapalli explained in a statement. "Our findings reinforce the idea that chronic inflammation, whether it's from an infection or a disease, can have an adverse role in CAD and heart health in general."

"These data remind us that other inflammatory states like lupus erythematosus, rheumatoid arthritis, and inflammatory bowel disease have also been linked to CAD, so perhaps we can add celiac disease to this list," echoed moderator Dr Jeffrey Kuvin(Tufts Medical Center, Boston, MA).

Celiac Disease on the Rise

Dr Rama Dilip Gajulapalli

Celiac disease affects an estimated one in 133 Americans, according to an ACC statement. However, more than 80% of people with the disease may be undiagnosed or wrongly diagnosed with, for example, lactose intolerance or irritable bowel syndrome. The disease is four times more common now than 50 years ago, and the only treatment is a gluten-free diet.

Celiac disease has been linked to arrhythmias and possible heart failure, so investigators hypothesized the disease is also associated with CAD.

They examined electronic health records of patients from 13 healthcare systems seen between January 1999 and September 2013. From nearly 22.4 million patients, they identified 24 530 diagnosed with celiac disease. The remaining patients served as controls.

The prevalence of CAD was significantly higher in all patients—as well as younger and older patients—with celiac disease than controls.

Prevalence of CAD in Patients With Celiac Disease

Age group CAD prevalence (%),patients with celiac disease(n=24 530) CAD prevalence (%), patients without celiac disease (n= 22 360 810) p
All ages (>18 y) 9.5 5.6 <0.0001
>65 y 28.6 13.2 <0.0001
18–65 4.5 2.4 <0.0001

"This is an important study because it highlights a specific patient population who might be at higher risk for CAD, even in the absence of traditional CV risk factors," Gajulapalli said. "We were surprised by the strength of the association, especially in younger people. Patients and doctors should be aware of this association."

Further prospective studies are needed to confirm the findings, however. Future research should also investigate whether the larger population with gluten sensitivity may also be at increased risk of CAD.

Full results from this study are being presented during ACC 2014 but were released early via a special preconference press briefing, focused on consumer-interest news.


  1. Gajulapalli RD, Pattanshetty DJ. Coronary artery disease prevalence is higher among celiac disease patients. Presented Saturday, March 29 at 1:30 p.m. EDT. American College of Cardiology 2014 Scientific Sessions ; March 29, 2014; Washington, DC. Abstract 1152-247

Wait. What? A mistake?

Hi Friends,

Here's an interesting article arguing against one of my latest blog posts concerning gluten and dementia written by Dr. David Perlmutter, Associate Professor at the University of Miami School of Medicine.

-- Dr. Dale


Is Avoiding Grains a Mistake?

Neal D. Barnard, MD

February 26, 2014Editor's Note: Medscape recently interviewed Dr. David Perlmutter, Associate Professor at the University of Miami School of Medicine, about his theory that carbohydrate and gluten consumption may cause or contribute to dementia. Dr. Neal D. Barnard, Adjunct Associate Professor of Internal Medicine at the George Washington University School of Medicine, doesn't agree. Here's why.

Grain and the Brain: A Lesson From Japan

It seems that many people are looking for a whipping boy on whom to blame our expanding waistlines, our diabetes epidemic, and our continuing need for cholesterol and blood pressure medications. Apparently they have found him: bread. It's not that grease-laden eggs-and-bacon breakfast, those fat-drenched chicken wings, or that sausage-and-cheese pizza that have caused our problems; it's that darn slice of bread.

Some clinicians and writers are going a step further. They are now flogging that whole-wheat whipping boy for triggering Alzheimer disease. But scientific evidence tells a very different story.

Grain-blaming started with the observation that high blood sugar levels are linked with Alzheimer disease. That's true enough. People with diabetes are at elevated risk of developing dementia.[1] So some have reasoned that because carbohydrates release natural sugars during digestion, the way to lower blood sugar must be to avoid carbs. They assumed that might protect the brain, too.

But here they have stepped on a scientific landmine. Avoiding healthy carbohydrate-containing foods turns out to be the last thing you would want to do for diabetes, obesity, or Alzheimer disease.

Take a lesson from Japan. In the 1960s and 1970s, Japan's dietary staple was rice. The Japanese diet was, of course, very high in carbohydrate, and yet diabetes was rare -- affecting a mere 1%-5% of adults older than 40 years.[2] In the ensuing years, westernization occurred rapidly. Meat displaced rice in Japanese meals and fat intake quickly climbed, while carbohydrate consumption plummeted. What was the result? By the 1990s, diabetes prevalence had risen dramatically. Clearly, carbohydrate was not the problem. The influx of fatty foods had elevated blood sugars and sparked a diabetes epidemic.

Americans have undergone a similar shift, albeit more gradually. In 1909, according to records from the US Department of Agriculture, American meat intake was 123.9 lb per person per year. Over the next century, meat intake soared, peaking at over 201.5 lb per person per year in 2004.[3] That's an average rise of more than 75 lb -- every person, every year. In the same interval, per capita cheese intake rose from less than 4 lb per year to nearly 34 lb. Grain intake went in the opposite direction: It fell substantially. Although it has partially rebounded in recent years, our consumption of flour and cereal products is far below 1909 levels.[4]

So it is not bread, rice, or grains in general that have caused blood sugars to rise or diabetes to become an epidemic. Just the opposite: The transition to a diet heavily based on animal products, especially meat and cheese, aided and abetted by fryer grease and sugar, is the real culprit in the current epidemics of obesity; diabetes; and, as we will see, Alzheimer disease.

We can't blame a lack of exercise either. Careful studies show that exercise patterns have not changed nearly enough to account for the dramatic rise in obesity.[5] The real problem is on the input side of the calorie equation.

But, you ask, aren't carbs fattening? The answer is no, and this is not rocket science. Carbohydrates have only 4 calories per gram. Fats have 9. So skipping meat and cheese and their load of fat is a great step for slimming down. In fact, the butter slathered over your morning toast is far denser in calories than the bread itself. Ditto for the cream cheese on a bagel, the meat sauce on your spaghetti, and the shortening baked into a cookie. Low-carb diets cause weight loss only when you leave out so many foods that your calorie intake falls. There is nothing magical or healthy about avoiding carbohydrates.

How Bad Fats Harm the Brain

But how could fatty foods, such as cheeseburgers and chicken wings, increase blood sugar? The answer appears to lie in the accumulation of fats inside muscle and liver cells. The metabolism of these intracellular lipids appears to disrupt insulin signaling, causing insulin resistance.[6]

While these mechanisms are still under investigation, our research group, with the support of the National Institutes of Health, tested the theory that getting these fats out of the diet would help. And it clearly does. In people with type 2 diabetes, a low-fat, plant-based diet causes significant weight loss and dramatic improvements in blood sugar control, not to mention reductions in plasma lipids and blood pressure. All this occurs in the absence of any limits on carbohydrates, calories, or portion sizes.[7]

As our diabetes study was bearing fruit, researchers at the Chicago Health and Aging Project published ground breaking findings showing that fatty foods were linked to Alzheimer disease. After 4 years of observation, saturated and trans fats were associated with increased Alzheimer risk.[8] Other studies have examined the same relationship, and although the data vary somewhat from study to study, the overall picture is that saturated and trans fats increase Alzheimer risk, just as they increase the risk for many other health problems.

It appears that the effect of these "bad" fats on cholesterol metabolism influences aspects of beta-amyloid deposition in the brain. This fits with 2 other observations: First, statins lower risk for Alzheimer disease, and second, the APOE epsilon 4 allele that is strongly associated with Alzheimer risk plays a major role in cholesterol transport.

Bottom line -- avoiding "bad" fats is a good idea.

In our studies and many others, people with diabetes, weight problems, lipid disorders, and other conditions discover the power of throwing out meat, cheese, and other animal products. As they replace them with healthy beans, grains, vegetables, and fruits, weight melts away, blood sugars fall, and the need for medications drops.

Does Gluten Matter?

What about gluten -- the protein found in wheat, barley, and rye? Is it harming your brain? Not likely. Here's what you need to know.

Roughly 1% of the population has celiac disease. They produce antibodies against a part of gluten called gliadin, which damages the intestinal tract and causes fatigue and mental fuzziness that disappear when gluten is avoided. A larger group of people -- perhaps around 6% or 7% -- have gluten sensitivity. For them, gluten causes no visible change in the intestinal lining but nonetheless does cause digestive and mental symptoms. They do well to avoid gluten, too.

But the vast majority of people -- more than 90% -- have no adverse reaction to gluten at all. For them, a gluten-free diet is the nutritional equivalent of omitting the 13th floor from a hotel architectural plan.

What About a Mediterranean Diet, or Maybe Paleo?

Many people are turning to "Mediterranean diets" or "Paleo diets," terms that are so appealing and meaningless that they have attracted millions of adherents.

"Mediterranean" conjures up summery images of yachts and glasses of wine by the seaside. But the Mediterranean region is vast and diverse, extending from Spain across southern Europe to Turkey, Lebanon, and Israel, and across North Africa. The culinary traditions in these regions vary dramatically. For one person, a "Mediterranean diet" might mean more olive oil. For another, it means pasta. For someone else, it's red wine, or maybe chickpeas or fresh fruit.

What these variants have in common is a reduced emphasis on animal-derived foods, which is in fact a step in the right direction. A traditional Asian diet would reduce animal products further, and a plant-based diet would remove them altogether -- both more powerful than a "Mediterranean" pattern.

"Paleo" brings images of our loincloth-clad forebears whose mastodon-conquering adventures are far more exhilarating than microwaving a frozen dinner while listening to NPR. The Paleolithic period is popularly understood as the band of human history beginning with the advent of stone tools and ending before the development of agriculture. So following a "Paleolithic diet," we get to eat meat, but we shun grains and anything else that requires a green thumb.

However, human evolution extends back much further than the Paleolithic period. Our primate ancestors were largely (or entirely) vegetarians, and our bodies are essentially pre-Stone-Age bodies that have never adapted to a meaty diet.

The most effective diet, by far, is plant-based. A plant-based diet reopens narrowed arteries, trims waistlines, lowers blood pressure, and is more powerful against diabetes than any other regimen. And it's surprisingly easy. When patients get good information and a bit of support, they benefit dramatically.

How to Do It in Your Practice

But how do we encourage our patients to change?

Here's how we do it with diabetic patients, but it works just as well with other conditions: When you see patients in your practice, invite them to attend an evening group session, which you schedule at a convenient time. Just as your office staff is turning out the lights at 5 PM, one staffer -- a nurse, dietitian, physician, or health coach -- turns the lights back on, puts the waiting room chairs in a circle, and welcomes 15-20 patients for a lecture. The staffer presents a simple class, or even easier, hits "play" on a DVD player, showing a short video. Twenty minutes later, the patients have learned how a plant-based diet works and the potential benefits it offers.

Now that patients are intrigued, everyone is asked to jot down ideas for plant-based foods that they would like to try. Common breakfast choices are oatmeal with cinnamon and raisins, a half-cantaloupe, whole-grain cereal with soy milk, rye or pumpernickel toast, veggie sausage, or tofu scramble. Lunch might be lentil soup, split-pea soup, or white bean chili with crusty bread and steamed vegetables. Or maybe pizza without cheese, but with extra sauce and veggie toppings. Dinner could be a green salad and a bowl of minestrone, followed by angel-hair pasta with artichoke hearts, seared oyster mushrooms, and chunky tomatoes, along with spinach lightly sautéed in garlic. Over the next week or so, participants are asked simply to test out these foods to see which ones they like.

One week later, everyone comes back to the office to compare notes. By now, they have a good feel for plant-based foods they enjoy. The next step is a 3-week test drive. For 21 days, everyone sets aside animal products and keeps oils to a minimum, with weekly meetings for support.

After 3 weeks, many choose to make the plant-based diet a permanent lifestyle change. They recognize how simple it is and like the feeling of taking control of their health, and they want to continue eating the foods that promote optimal health. They also notice that their tastes are changing so as to embrace new, healthy foods. We have codified this program into a simple curriculum that we make available to clinicians anywhere.

It's time to give that whipping boy a reprieve. Healthy grains, beans, vegetables, and fruits have power that no other regimen can match.


  1. Ohara T, Doi Y, Ninomiya T, et al. Glucose tolerance status and risk of dementia in the community: the Hisayama study. Neurology. 2011;77:1126-1134. Abstract
  2. Kuzuya T. Prevalence of diabetes mellitus in Japan compiled from literature. Diabetes Res Clin Pract. 1994;24 Suppl:S15-S21. Abstract
  3. US Department of Agriculture, Economic Research Service. Food availability (per capita) data system. December 18, 2013. Accessed February 18, 2014.
  4. Barnard ND. Trends in food availability, 1909-2007. Am J Clin Nutr. 2010;91:1530S-1536S. Abstract
  5. Swinburn B, Sacks G, Ravussin E. Increased food energy supply is more than sufficient to explain the US epidemic of obesity. Am J Clin Nutr. 2009;90:1453-1456. Abstract
  6. Samuel VT, Petersen KF, Shulman GI. Lipid-induced insulin resistance: unravelling the mechanism. Lancet. 2010;375:2267-2277. Abstract
  7. Barnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. Diabetes Care. 2006;29:1777-1783. Abstract
  8. Morris MC, Evans EA, Bienias JL, et al. Dietary fats and the risk of incident Alzheimer's disease. Arch Neurol. 2003;60:194-200. Abstract

Headaches?! Read this.

Love today's article from the Huffington Post.   I have many patients who have headaches issues.  One huge trigger for headaches is gluten/celiac symptoms.  Come stop by the office for a celiac check-up, or to be referred to our favorite food allergy/sensitivity clinics. I got you.

-- Dr. Dale

Experts agree that knowing your triggers is one of the best ways to avoid the searing or pounding pain of a headache.

Triggers can be diet-related, and chronic headache sufferers often learn which eats and drinks are best for them to avoid. But if certain foods are off limits, are there also foods that help?

The evidence is less convincing, but there are a few potential pain-savers. The six foods below probably won't make a headache disappear completely, but they do seem to have preventive powers.

7 Things Only Gluten-Free People Understand

Aside from specializing in Anal Warts (HPV), Hemorrhoids and Colonoscopies, as I'm also a gastroenterologist I handle hundreds of celiac cases each month.  Many of my patients who are suffering from "celiac" and "non celiac gluten sensitivity" are afraid of the life before them should they decide to change their eating habits.  As gluten-free alternative have matriculated into our grocery stores (even Ralph's sells gluten free), and at our sandwich shop (Mendocino Farms is the best), it's become much easier to have gluten-free offered to you versus digging to find it. -- Dr. Dale


7 Things Only Gluten-Free People Understand

Despite the trendiness of going gluten-free, only about 1 in 133 people truly have celiac disease, an autoimmune disorder that causes damage to the small intestine when gluten is ingested. Another small group have a condition doctors call "non-celiac gluten sensitivity" that can also produce symptoms.

In addition to the stomach trouble, joint pain, mood swings and other symptoms, people who don't eat gluten often also face seemingly-endless peeving comments like, "I could never give up bread!"

But dealing with both uncomfortable symptoms and uncomfortable situations has a silver lining: There are certain lessons learned by only those who eat gluten-free. We asked our Twitter followers and Facebook fans to share some of those truths with us. Here are a few of our favorites. If you're gluten-free, you know... 1. That there are so many other yummy, yummy alternatives! --Tara Francy Brown

gluten free alternatives 2. That the people serving, selling and distributing your food really have no clue how it is made, and what is in it. --Dylan Armstrong 3. Processed foods have taken over. --Optamus Primel

gluten free processed foods 4. How much gluten can affect both physical and mental wellbeing. --Laura B. Russell 5. Gluten is hidden in soy sauce, beer, some mocha powders in coffee shops and many salad dressings. --Elizabeth Paul

soy sauce gluten 6. How good you feel without it!! --@FayeWoodhead 7. That's there's tons of food that I can eat. --Debbie Cronrath Hassel quinoa