Dr. Fasano: Different Processes Involved in Celiac Disease, Gluten Sensitivity

Gluten sensitivity represents a completely different condition from celiac disease, and the vast majority of people who have gluten sensitivity (also known as gluten intolerance) will never develop celiac, says top celiac disease researcher Dr. Alessio Fasano.

However, there's no doubt that gluten sensitivity is a real condition, and it potentially affects more than one out of every 20 people, Dr. Fasano told me in an interview this morning. He and his colleagues at the University of Maryland's Center for Celiac Research published a paper last week proving for the first time that gluten sensitivity exists.

"We're talking about 20 million people out there," he says. "This gives some rational reason why people come up with the symptoms they have."

People with celiac disease have specific damage to their intestines caused by an autoimmune reaction to gluten in their diets. People with gluten sensitivity don't have this damage, although they do experience inflammation from gluten, Dr. Fasano says.

The difference between the two conditions stems from the immune system response to gluten.

In gluten sensitivity, the innate immune system -- the body's first line of defense against invaders -- responds to gluten ingestion by fighting the gluten directly, creating inflammation both inside and outside the digestive system, Dr. Fasano says.

Meanwhile, in celiac disease, both the innate immune system and the adaptive immune system -- a more advanced, sophisticated part of the immune system -- get involved in the fight, he says. Miscommunications between adaptive immune system cells lead those cells to fight the body's own tissues, creating the villous atrophy seen in celiac disease.

Some people identified as gluten-sensitive in the University of Maryland study showed some intestinal damage. However, that damage has different biomarkers than those seen in celiac disease, and it's very unlikely that those gluten sensitive people would eventually be diagnosed with celiac, Dr. Fasano says.

There's no question that people with celiac disease and gluten sensitivity experience near-identical symptoms, including diarrhea, bloating, abdominal pain, joint pain, depression, brain fog and migraines, Dr. Fasano says.

Only those people with the adaptive immune system response unique to celiac disease are at risk for developing intestinal lymphoma and other conditions associated with celiac, such as osteoporosis, he says. However, gluten sensitivity appears to play a role in 20% or more of patients with autism and schizophrenia, he says.

Dr. Fasano says he first became interested in exploring the possibility of gluten sensitivity within the last two or three years. Before then, he says, he would tell people who tested negative for celiac disease that gluten couldn't possibly be their problem, even if those people were convinced that gluten was causing their symptoms.

"In the last two years, we've been inundated with people who come to the clinic thinking they have celiac disease. The vast majority do not," he says. "What this paper does is give some proof at the molecular level that gluten sensitivity exists."

Dr. Fasano says the research into gluten sensitivity is in its early infancy, and that more studies are needed to further pin down the condition and to differentiate between people who have gluten sensitivity and early celiac disease.

The University of Maryland study identified biomarkers that can be used to diagnose gluten sensitivity. However, the researchers used endoscopies with intestinal biopsies to collect those biomarkers, which isn't a practical way to diagnose gluten sensitivity in 6% of the population, Dr. Fasano says.

The next step will be to create blood tests that can easily screen for gluten sensitivity. Dr. Fasano says he anticipates such tests will be available within the next couple of years.