Celiac disease vs crohn’s

Celiac disease and Crohn’s disease both cause inflammation of the intestines, and although there are some overlapping symptoms each condition has its own unique disease course that requires a very specific form of treatment.

Distinguishing celiac disease and Crohn’s disease based on symptoms alone could be quite difficult. Additional testing is required for determining the exact diagnosis. What can make diagnosing even more challenging is that many Crohn’s disease patients will have celiac disease as well, so treatments must be combined in order to offer the patient relief.

Genetics is now being studied to determine the genetic differences between Crohn’s disease and celiac disease, and although many genetic differences have been found already there is still much to uncover about either condition.

Here we will outline the similarities and differences between celiac disease and Crohn’s disease, along with symptoms, causes, and treatment methods to help you better understand each unique disease.

Celiac disease vs. Crohn’s disease: U.S. prevalence and economic impact

Crohn’s disease, which is an inflammatory bowel disease (IBD), typically occurs in younger adults aged 15 to 30. Crohn’s disease is more common in areas further from the equator, with the highest rates of Crohn’s disease seen in Canada.

Prevalence of Crohn’s disease in the U.S. is 26 to 199 per 100,000 persons. There has been a 74 percent increase in doctors’ visits since 1992 for Crohn’s disease, and the annual direct medical costs for Crohn’s disease amount to $18,932 per patient in the U.S.

One in every 141 people in the U.S. has celiac disease, but many patients often go undiagnosed so the rate may be higher. The risk of a person developing celiac disease is higher if they have family members who had the disease. The condition is also commonly seen in type 1 diabetics, people with Down syndrome, Turner syndrome, autoimmune conditions, and collagenous colitis.

The total U.S. healthcare costs for untreated celiac disease are between $14.5 and $34.8 billion annually.

Comparing celiac disease and Crohn’s disease signs and symptoms

Genetically and symptomatically speaking, both Crohn’s disease and celiac disease have much in common, but it’s important to note that there are very important differences between the two as well.

Shared symptoms include abdominal pain, diarrhea, anemia, rectal bleeding, inflammation of the intestines (uncovered by a scope), weight loss, and fever.

Previous research found that celiac disease and Crohn’s disease share some of their genetic background. Researchers combined meta-analysis of genome-wide data for both diseases and found some shared risk loci.

Although some aspects of celiac disease and Crohn’s disease are understood, there are still many questions left unanswered. Researchers do know that genetic and environmental factors play a role in both diseases. Celiac disease is more common than Crohn’s disease, and although celiac is known to be triggered by gluten, less is known about the exact cause of Crohn’s disease.

It has been revealed that celiac patients are at a higher risk for Crohn’s disease, meaning the two conditions may share some genetic background.

Despite these advances, further research is still required to fully understand the exact mechanisms behind both diseases.

Symptoms of Crohn’s disease include diarrhea, fever, fatigue, abdominal pain and cramping, blood in stool, mouth sores, reduced appetite and weight loss, and perianal disease characterized by the drainage from the anus.

Symptoms of celiac disease are weight loss, vomiting, abdominal bloating and pain, persistent diarrhea or constipation, and pale, fatty, foul-smelling stool.

Crohn’s versus celiac disease: Causes

Both celiac disease and Crohn’s disease are autoimmune disorders, meaning the immune system attacks itself mistaking itself for a threat. In celiac disease, the immune system believes that gluten is a threat, so it attacks gluten upon ingesting thus causing the related symptoms. The cause of Crohn’s disease is still unclear, but it has been previously suggested that diet and stress may play a role.

It has also been speculated that bacteria may lead to Crohn’s disease, causing an abnormal immune response when the immune system attacks the digestive system and the intestines. Furthermore, Crohn’s disease has been found to be of higher prevalence within families, revealing a possible genetic link.

Crohn’s vs. celiac disease: Risk factors and complications

Although the exact cause of Crohn’s disease is unknown, there are notable risk factors that may increase one’s odds of developing the condition. Risk factors for Crohn’s disease include age (younger than 30 years), being Eastern European, having family history of Crohn’s disease, smoking, taking nonsteroidal anti-inflammatory medications, and living in an industrial country or northern climates.

Risk factors for celiac disease include family history of the condition, type 1 diabetes, Down syndrome or Turner syndrome, autoimmune thyroid disease, Sjögren’s syndrome, and microscopic colitis.

Complications can arise in Crohn’s disease including inflammation through the bowel – which can cause narrowing, scarring, or fistulas, bowel obstructions that require surgery to clear, ulcers, anal fissures, malnutrition, colon cancer, anemia, osteoporosis, gallbladder, or liver disease. Complications may arise from the use of medications, including problems with the immune system or cancer.

Celiac disease complications include malnutrition, loss of calcium and bone density (osteoporosis), infertility or miscarriages, lactose intolerance and cancer.

Distinguishing between Crohn’s and celiac disease: Diagnosis and treatment

Crohn’s disease and celiac disease are diagnosed with a detailed medical and family history along with additional testing. For celiac disease, blood tests check the complete blood count, liver function, cholesterol levels, alkaline phosphatase, and serum albumin. A skin biopsy can also be taken for sample examination under the microscope.

If blood tests and a skin biopsy are inconclusive, then endoscopy or colonoscopy will be performed, and an internal biopsy from the intestines will be completed.

Because Crohn’s disease can mimic other conditions like infections, diverticulitis, and cancer, it’s important to rule out these other possible causes. Blood tests are ineffective in diagnosing Crohn’s disease, so an ultrasound, CT scan, MRI, colonoscopy, and internal biopsy may be conducted.

Celiac disease is far easier to treat than Crohn’s disease, because in the former as long as the patient doesn’t consume gluten symptoms will subside and no additional complications will occur.

Crohn’s disease, on the other hand, has a longer list of treatment methods because it does not have an exact cause to target. Treatment for Crohn’s disease may include corticosteroids, anti-inflammatory drugs, immunosuppressant agents, antibiotics, biologic agents, nutritional and dietary counseling, stress management, and, in severe Crohn’s disease cases, surgery to remove heavily affected areas of the intestines and colon.

Celiac disease vs. Crohn’s disease: Lifestyle and prevention tips

Celiac disease can be well managed by following a strict gluten-free diet. This includes avoiding wheat, spelt, rye, barley, triticale, bulgur, durum, farina, graham flour, and semolina. Natural gluten-free grains include buckwheat, cornmeal, amaranth, arrowroot, potatoes, beans, rice and rice flour, quinoa, and tapioca.

Living with Crohn’s disease comes with some dietary modifications as well. Some common foods to avoid with Crohn’s disease are beans, cabbage, broccoli, and raw fruits and juices. It is also advised that you consume six small meals as opposed to three large ones to aid in digestion. You may also wish to avoid dairy, high fiber foods, spicy foods, alcohol, and caffeine, which can worsen symptoms.

It’s also important to reduce stress and quit smoking, as both factors can aggravate the disease and contribute to symptom flares.

Because both celiac disease and Crohn’s disease are autoimmune diseases, prevention may not be foolproof, but controlling your modifiable risk factors as best as possible may be able to lower your risk of either disease.

Related: Celiac disease vs. IBS, differences in symptoms, causes, and treatment

Prevalence of inflammatory bowel disease among coeliac disease patients in a Hungarian coeliac centre

  1. 1.

    Husby S, Koletzko S, Korponay-Szabó IR, Mearin ML, Phillips A, Shamir R, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr. 2012;54(1):136–60.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  2. 2.

    Kocsis D, Miheller P, Lőrinczy K, Herszényi L, Tulassay Z, Rácz K, et al. Coeliac disease in a 15-year period of observation (1997 and 2011) in a Hungarian referral centre. Eur J Intern Med. 2013;24(5):461–7.

    • PubMed
    • Article
    • Google Scholar
  3. 3.

    Diamanti A, Capriati T, Bizzarri C, Panetta F, Ferretti F, Ancinelli M, et al. Celiac disease and endocrine autoimmune disorders in children: an update. Expert Rev Clin Immunol. 2013;9(12):1289–301.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  4. 4.

    Festen EA, Goyette P, Green T, Boucher G, Beauchamp C, Trynka G, et al. A meta-analysis of genome-wide association scans identifies IL18RAP, PTPN2, TAGAP, and PUS10 as shared risk loci for Crohn’s disease and celiac disease. PLoS Genet. 2011;7(1):e1001283.

    • CAS
    • PubMed
    • PubMed Central
    • Article
    • Google Scholar
  5. 5.

    Cronin CC, Shanahan F. Anemia in patients with chronic inflammatory bowel disease. Am J Gastroenterol. 2001;96(8):2296–8.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  6. 6.

    Annibale B, Severi C, Chistolini A, Antonelli G, Lahner E, Marcheggiano A, et al. Efficacy of gluten-free diet alone on recovery from iron deficiency anemia in adult celiac patients. Am J Gastroenterol. 2001;96(1):132–7.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  7. 7.

    Masachs M, Casellas F, Malagelada JR. Inflammatory bowel disease in celiac patients. Rev Esp Enferm Dig. 2007;99(8):446-50.

    • Google Scholar
  8. 8.

    Lakatos PL. Recent trends in the epidemiology of inflammatory bowel diseases: up or down? World J Gastroenterol. 2006;12(38):6102–8.

    • PubMed
    • PubMed Central
    • Article
    • Google Scholar
  9. 9.

    Cooper BT, Holmes GK, Cooke WT. Coeliac disease and immunological disorders. Br Med J. 1978;1(6112):537–9.

    • CAS
    • PubMed
    • PubMed Central
    • Article
    • Google Scholar
  10. 10.

    Breen EG, Coghlan G, Connolly EC, Stevens FM, McCarthy CF. Increased association of ulcerative colitis and coeliac disease. Ir J Med Sci. 1987;156(4):120–1.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  11. 11.

    Kitis G, Holmes GK, Cooper BT, Thompson H, Allan RN. Association of coeliac disease and inflammatory bowel disease. Gut. 1980;21(7):636–41.

    • CAS
    • PubMed
    • PubMed Central
    • Article
    • Google Scholar
  12. 12.

    Delcò F, El-Serag HB, Sonnenberg A. Celiac sprue among US military veterans: associated disorders and clinical manifestations. Dig Dis Sci. 1999;44(5):966–72.

    • PubMed
    • Article
    • Google Scholar
  13. 13.

    Yang A, Chen Y, Scherl E, Neugut AI, Bhagat G, Green PH. Inflammatory bowel disease in patients with celiac disease. Inflamm Bowel Dis. 2005;11(6):528–32.

    • PubMed
    • Article
    • Google Scholar
  14. 14.

    Leeds JS, Höroldt BS, Sidhu R, Hopper AD, Robinson K, Toulson B, et al. Is there an association between coeliac disease and inflammatory bowel diseases? A study of relative prevalence in comparison with population controls. Scand J Gastroenterol. 2007;42(10):1214–20.

    • PubMed
    • Article
    • Google Scholar
  15. 15.

    Casella G, D’Incà R, Oliva L, Daperno M, Saladino V, Zoli G, et al. Prevalence of celiac disease in inflammatory bowel diseases: an IG-IBD multicentre study. Dig Liver Dis. 2010;42(3):175–8.

    • PubMed
    • Article
    • Google Scholar
  16. 16.

    Vermeire S, Noman M, Van Assche G, Baert F, Van Steen K, Esters N, et al. Autoimmunity associated with anti-tumor necrosis factor alpha treatment in Crohn’s disease: a prospective cohort study. Gastroenterology. 2003;125(1):32–9.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  17. 17.

    Snook JA, de Silva HJ, Jewell DP. The association of autoimmune disorders with inflammatory bowel disease. Q J Med. 1989;72(269):835–40.

    • CAS
    • PubMed
    • Google Scholar
  18. 18.

    Casella G, Perego D, Baldini V, Monti C, Crippa S, Buda CA. A rare association between ulcerative colitis (UC), celiac disease (CD), membranous glomerulonephritis, leg venous thrombosis, and heterozygosity for factor V Leiden. J Gastroenterol. 2002;37(9):761–2.

    • PubMed
    • Article
    • Google Scholar
  19. 19.

    Cheng SX, Raizner A, Phatak UP, Cho JH, Pashankar DS. Celiac disease in a child with ulcerative colitis: a possible genetic association. J Clin Gastroenterol. 2013;47(2):127–9.

    • PubMed
    • PubMed Central
    • Article
    • Google Scholar
  20. 20.

    Shah A, Mayberry JF, Williams G, Holt P, Loft DE, Rhodes J. Epidemiological survey of coeliac disease and inflammatory bowel disease in first-degree relatives of coeliac patients. Q J Med. 1990;74(275):283–8.

    • CAS
    • PubMed
    • Google Scholar
  21. 21.

    Cottone M, Marrone C, Casà A, Oliva L, Orlando A, Calabrese E, et al. Familial occurrence of inflammatory bowel disease in celiac disease. Inflamm Bowel Dis. 2003;9(5):321–3.

    • PubMed
    • Article
    • Google Scholar
  22. 22.

    Green PH, Jabri B. Coeliac disease. Lancet. 2003;362(9381):383–91.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  23. 23.

    Di Tola M, Sabbatella L, Anania MC, Viscido A, Caprilli R, Pica R, et al. Anti-tissue transglutaminase antibodies in inflammatory bowel disease: new evidence. Clin Chem Lab Med. 2004;42(10):1092–7.

    • PubMed
    • Article
    • Google Scholar
  24. 24.

    Farrace MG, Picarelli A, Di Tola M, Sabbatella L, Marchione OP, Ippolito G, et al. Presence of anti-“tissue” transglutaminase antibodies in inflammatory intestinal diseases: an apoptosis-associated event? Cell Death Differ. 2001;8(7):767–70.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  25. 25.

    Bizzaro N, Villalta D, Tonutti E, Doria A, Tampoia M, Bassetti D, et al. IgA and IgG tissue transglutaminase antibody prevalence and clinical significance in connective tissue diseases, inflammatory bowel disease, and primary biliary cirrhosis. Dig Dis Sci. 2003;48(12):2360–5.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  26. 26.

    Schuffler MD, Chaffee RG. Small intestinal biopsy in a patient with Crohn’s disease of the duodenum. The spectrum of abnormal findings in the absence of granulomas. Gastroenterology. 1979;76(5 Pt 1):1009–14.

    • CAS
    • PubMed
    • Google Scholar
  27. 27.

    Wright CL, Riddell RH. Histology of the stomach and duodenum in Crohn’s disease. Am J Surg Pathol. 1998;22(4):383–90.

    • CAS
    • PubMed
    • Article
    • Google Scholar
  28. 28.

    Culliford A, Markowitz D, Rotterdam H, Green PH. Scalloping of duodenal mucosa in Crohn’s disease. Inflamm Bowel Dis. 2004;10(3):270–3.

    • PubMed
    • Article
    • Google Scholar
  29. 29.

    Oxford EC, Nguyen DD, Sauk J, Korzenik JR, Yajnik V, Friedman S, et al. Impact of coexistent celiac disease on phenotype and natural history of inflammatory bowel diseases. Am J Gastroenterol. 2013;108(7):1123–9.

    • PubMed
    • Article
    • Google Scholar
  30. 30.

    Dickey W, Bodkin S. Prospective study of body mass index in patients with coeliac disease. BMJ. 1998;317(7168):1290.

    • CAS
    • PubMed
    • PubMed Central
    • Article
    • Google Scholar
  31. 31.

    Nusier MK, Brodtkorb HK, Rein SE, Odeh A, Radaideh AM, Klungland H. Serological screening for celiac disease in schoolchildren in Jordan. Is height and weight affected when seropositive? Ital J Pediatr. 2010;36:16.

    • PubMed
    • PubMed Central
    • Google Scholar
  32. 32.

    Mijac DD, Janković GL, Jorga J, Krstić MN. Nutritional status in patients with active inflammatory bowel disease: prevalence of malnutrition and methods for routine nutritional assessment. Eur J Intern Med. 2010;21(4):315–9.

    • PubMed
    • Article
    • Google Scholar
  33. 33.

    Durusu M, Gürlek A, Simşek H, Balaban Y, Tatar G. Coincidence or causality: celiac and Crohn diseases in a case of Turner syndrome. Am J Med Sci. 2005;329(4):214–6.

    • PubMed
    • Article
    • Google Scholar
  34. 34.

    Patel J, Agasti A, Rao S, Srinivas MG, Patel M, Sawant P. Celiac disease preceding Crohn’s disease? Trop Gastroenterol. 2011;32(3):236–8.

    • PubMed
    • Google Scholar
  35. 35.

    Dickey W. A case of sequential development of celiac disease and ulcerative colitis. Nat Clin Pract Gastroenterol Hepatol. 2007;4(8):463–7.

    • PubMed
    • Article
    • Google Scholar
  36. 36.

    Von Tirpitz C, Pischulti G, Klaus J, Rieber A, Brückel J, Böhm BO, et al. Pathological bone density in chronic inflammatory bowel diseases—prevalence and risk factors. Z Gastroenterol. 1999;37(1):5–12.

    • Google Scholar
  37. 37.

    Siffledeen JS, Fedorak RN, Siminoski K, Jen H, Vaudan E, Abraham N, et al. Bones and Crohn’s: risk factors associated with low bone mineral density in patients with Crohn’s disease. Inflamm Bowel Dis. 2004;10(3):220–8.

    • PubMed
    • Article
    • Google Scholar
  38. 38.

    Keaveny AP, Freaney R, McKenna MJ, Masterson J, O’Donoghue DP. Bone remodeling indices and secondary hyperparathyroidism in celiac disease. Am J Gastroenterol. 1996;91(6):1226–31.

    • CAS
    • PubMed
    • Google Scholar
  39. 39.

    Duerksen DR, Leslie WD. Positive celiac disease serology and reduced bone mineral density in adult women. Can J Gastroenterol. 2010;24(2):103–7.

    • PubMed
    • PubMed Central
    • Article
    • Google Scholar
  40. 40.

    Bianchi ML. Inflammatory bowel diseases, celiac disease, and bone. Arch Biochem Biophys. 2010;503(1):54–65.

    • CAS
    • PubMed
    • Article
    • Google Scholar

Crohn’s and Gluten: Why Elimination Diets May Not Be Enough

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Article Summary:

  • Gluten can have a detrimental impact on patients with Crohn’s disease, regardless of whether or not they have a discrete gluten intolerance
  • A number of gluten-free diets can help patients eliminate gluten, but evidence for their therapeutic efficacy is inconsistent
  • Nutritional supports designed to enhance gut microbiome health, such as butyric acid supplements, may work in concert with gluten-free diets or be used on their own to give patients effective and durable symptom relief

Gluten intolerance is traditionally associated with celiac disease, but this understanding is shifting as the medical community increasingly recognizes both non-celiac gluten sensitivity and the impact of gluten on other health conditions. In particular, the relationship between gluten and Crohn’s disease has become a critical area of interest, spurring many patients to consider gluten-free diets (GFDs) as potentially effective treatments. By exploring the current literature, clinicians and patients can come to understand both the potential and limits of gluten elimination and why additional dietary supports in the form of supplementation may be necessary to achieve symptom remission.

The Impact Of Gluten Consumption on Crohn’s Disease Patients

Despite the close relationship between celiac disease and gluten intolerance, gluten sensitivity is experienced by individuals without celiac disease. As Chris Kresser, director of the California Center For Functional Medicine, states, “It’s becoming more and more clear that celiac disease is only one manifestation of gluten intolerance, and that ‘non-celiac gluten sensitivity’ (i.e. people that react to gluten but do not have celiac disease) is a legitimate health condition.” As Kresser notes, gluten sensitivity is newly recognized as a pathology in its own right rather than as a symptom of other underlying pathologies like it is in celiac disease and such sensitivity can aggravate symptoms of co-occurring Crohn’s disease. Additionally, patients with Crohn’s may be susceptible to gluten-induced gastrointestinal distress due to the impact of gluten on the gut microbiome. In light of this understanding, the rationale for using a gluten-free diet is twofold:

Gluten Sensitivity In Crohn’s Patients

Crohn’s disease patients can have gluten intolerance that is separate from their Crohn’s pathology but augments Crohn’s symptoms when triggered. This occurs when B-cells of the immune system are activated by gluten consumption and consistently and incorrectly produce antibodies against it, inducing a minor allergic reaction and subsequent inflammation. While this may occur in non-Crohn’s patients, those with Crohn’s are particularly vulnerable to such a reaction due to abnormally active immune cells in the GI tract, which occurs independently of specific allergens. As a result, Crohn’s patients produce antibodies against many common but harmless antigens present in food, leading to heightened risk of immune activation and inflammation while still stopping short of a major allergic reaction. Although wheat gluten antigens are just one set of many other antigens which may trigger Crohn’s disease patients into a flare-up, gluten is a particularly common culprit; one study found that 29.3% of Crohn’s patients experienced non-celiac gluten sensitivity.

The Effect of Gluten on the Microbiome

In addition to the inflammation caused by allergic reaction, gluten may cause inflammation of the GI tract by inducing dysbiosis, thereby destabilizing the gut microbiome’s bacterial proportions. Dysbiosis means that the immune system is allowing or causing harmful bacteria to out-compete bacteria that are characteristic of a healthy microbiome. Once the microbiome is disrupted by an abundance of easy-to-consume fuel in the form of wheat gluten proteins, unhealthy bacteria can rapidly replicate themselves and displace normal microbiomic fauna, causing the immune system to generate more inflammation. Inflammation and de-inflammation cycles can then cause micro-tearing of the intestinal surfaces, causing bleeding and bloody stools.

Additionally, Crohn’s patients often require microbiome-disrupting treatments like antibiotics to control their symptoms. As Kresser notes, “Just a single course of antibiotics can reduce the richness and diversity of the intestinal microbiota, and in many cases, people never completely regain the diversity they lost.” Considering the potential detrimental effects that gluten can have on the microbiome and the generally disrupted state of the microbiome in Crohn’s patients, minimizing consumption of gluten may thus make the difference between a destabilized and a balanced microbiome.

Gluten-Free Diets For Crohn’s

Given the links between gluten and Crohn’s symptoms, a growing body of research highlights the potential advantages of gluten elimination. One particularly promising investigation found that 65.6% of Crohn’s patients experienced an improvement in one or more of their symptoms while on a GFD. These improvements allowed 23.6% of patients to use fewer medications to prevent flare-ups and 38.3% of patients reported fewer flare-ups overall. This data suggests that GFDs can have a meaningful impact on many Crohn’s patients, improving treatment outcomes and quality of life.

While the study did not inquire about the specific GFD used by participants, there are several GFDs that have been investigated for their efficacy in treating Crohn’s disease and other IBDs:

SCD

The most heavily-researched GFD used by Crohn’s patients is the specific carbohydrate diet (SCD). Originally intended to treat the symptoms of celiac disease before celiac disease itself was characterized, the SCD’s goal is to control the gut microbiome by regulating carbohydrates the are easy for bacteria to break down. In practice, this means eliminating the majority of carbohydrates altogether, with a particular emphasis on removing those which may produce gas when digested, including all grains. As a result, SCD is incidentally gluten-free.

A study investigating the efficacy of different diets in the context of Crohn’s disease and ulcerative colitis found that the SCD helped both sets of patients. The study found that 42% of Crohn’s disease and ulcerative colitis patients experienced reduced inflammation and gastrointestinal disturbances after 6 months of the SCD. Of this 42%, 13% reported that remission began within two weeks of starting on the SCD. However, the SCD isn’t sufficient to slow down flaring Crohn’s symptoms; once an inflammatory chain reaction begins, it’s too late to switch to a different diet. Additionally, the SCD was not designed with a modern understanding of microbiome health or Crohn’s disease. As such, it is not an optimal strategy for Crohn’s patients, despite being helpful for some.

CDED

Originally invented by Drs. Stein and Baldrassano of the Children’s Hospital of Pennsylvania, the Crohn’s Disease Exclusion Diet (CDED) is a new GFD designed specifically to promote microbiome health and reduce symptoms in Crohn’s patients. By excluding those foods to which Crohn’s patients are most likely to experience sensitivity—gluten, milk, beef, pork and eggs—diet seeks to prevent the runaway inflammation that damages the microbiome.

As an emerging treatment, the CDED remains under investigation. Currently, a major clinical trial is underway to assess effectiveness following several promising pilot studies. With the CDED trial expected to end in July 2019, its utility isn’t yet known.

FODMAP Exclusion Diets

The FODMAP (Fermentable Oligo-/Di-/Mono-saccharides And Polyols) exclusion diets are designed to treat a wide variety of gastrointestinal disorders ranging from irritable bowel syndrome (IBS) to inflammatory bowel syndromes like Crohn’s by reducing the intake of foods which produce large volumes of gas when fermented in the intestinal tract. FODMAP diets are often incidentally gluten-free, though their main focus is on the exclusion of certain carbohydrates known as FODMAPs which are poorly absorbed by the GI tract.

The evidence for FODMAP diets in Crohn’s disease is conflicting. A number of studies have found that FODMAP exclusion diets are linked to reduced GI inflammation and other symptoms in inflammatory bowel diseases. Other studies, however, have not replicated these results. Furthermore, FODMAP diets may cause reduced butyrate production and maladaptive changes in the microbiome, which could potentially lead to increased GI inflammation. Future research will clarify the conflict and determine whether FODMAP diets are useful.

A Possible Explanation for Inconsistent Findings

While diets may provide relief to some patients, the inconsistent evidence finding on the efficacy of GFDs for Crohn’s patients may have an explanation. The group of human leukocyte antigen (HLA) alleles that make up the variable gene complex (haplotype) of the immune system is a large factor. The efficacy of GFDs in Crohn’s patients is likely linked to the HLA-DQ2 and -DQ8 haplotypes, with one study finding that only 12% of patients with IBDs and without these haplotypes experienced symptom abatement after 6 months on a GFD. In contrast, 60% of patients with either of the haplotypes experienced symptom abatement. Because 60% of Crohn’s patients don’t have either haplotype, these findings suggest that GFDs will not be effective for the majority of patients.

Adjunctive Nutritional Supplementation

Despite not being effective for all patients, GFDs can have an important place within Crohn’s treatment protocols. However, the shortcomings of these diets and their restrictive nature leave many clinicians and Crohn’s patients searching for better dietary alternatives for alleviating symptoms not fully addressed by conventional treatments. Nutritional supplementation designed to promote microbiome health presents new possibilities for symptom relief for both those using GFDs and those for whom they are ineffective.

Supplements targeting the microbiome seek to restore a healthy balance of bacterial colonies in order to reduce inflammation and support optimal function. As a result, nutritional supplementation could be a partner treatment to other treatments, including GFDs, to help correct both natural and treatment-induced microbiome disruption as well as augment other microbiome-supporting therapies. By integrating multiple therapies designed to promote microbiome health, Crohn’s patients may be able to address specific symptoms while building resilience against flare-ups caused by a distorted microbiome, promoting more stable remission.

One of the most promising nutritional supplements for Crohn’s patients is butyric acid, a cellular signaling molecule in the GI tract that is deficient in people with Crohn’s patients. By providing the GI tract’s immune cells with the butyric acid that they’re missing, they can better regulate and normalize the microbiome. Evidence suggests that this type of supplementation can have significant effects; one study found that 69% of participants responded to bioavailability-optimized orally administered butyrate supplementation, with 53% achieving symptom remission. In the patients who responded, inflammation markers and mucosal secretions were reduced significantly.

Further research is necessary to more fully understand the potential of butyrate supplementation in Crohn’s treatment. However, for now, its use in addition to conventional treatments and non-conventional treatments like GFDs may provide relief to patients when other treatments in isolation could not. Other supplements like fish oil exist in a similar state, with some evidence in favor of their benefit in Crohn’s and many questions left to be answered.

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Works Cited

Kresser, C. (2017). Should you go gluten-free? https://chriskresser.com

Gluten-Free Living: Gluten, Crohn’s and Ulcerative Colitis

Gluten-Free Living magazine recently interviewed Kelly Issokson, MS, RD, CNSC, a registered dietician in the Nutrition and Integrative Inflammatory Bowel Disease (IBD) program at Cedars-Sinai, about the connection between gluten, Crohn’s Disease and Ulcerative Colitis.

The article cites a recent study that found almost one in five IBD patients tries a gluten-free diet. Of those who decide to eat gluten-free diets, two-thirds report improved symptoms and 38 percent report fewer or less-severe flare-ups between periods of remission. This was the largest study of the gluten-free diet in patients with IBD, including a total of 1,647 participants.

However, Issokson says the benefits of a gluten-free diet might not relate directly to gluten.

“Gluten-containing foods are also a significant source of fructan, a type of FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols), which has been associated with functional gastrointestinal symptoms in irritable bowel syndrome and IBD,” Issokson told Gluten-Free Living.

According to the article, recent analysis by Chinese researchers found IBD patients on a low-FODMAP diet showed significant improvement in multiple symptoms.

“Thus, a short-term, low-FODMAP diet or even a diet with a reduction in fructans may be a better choice and lead to symptom improvement without the need to follow a long-term gluten-free diet,” Issokson told Gluten-Free Living.

Issokson added that whenever a patient is interested in starting a gluten-free diet she recommends first getting tested for celiac disease. “Testing for celiac has many benefits, including helping the patient understand how strict they need to be on a gluten-free diet,” Issokson told Gluten-Free Living.

For symptom management, Issokson also stresses the importance of a balanced diet for gut healing and overall health, how certain foods can contribute to gastrointestinal symptoms, and about how reducing stress and increasing physical activity can help manage symptoms.

“Restricted diets can decrease quality of life, increase risk for malnutrition and slow the healing process. My goal is to help achieve nutritional balance through the least restrictive diet possible,” Issokson said.

Click here to read the compliete Gluten-Free Living article.

Read more on the Cedars-Sinai Blog: Is Eating Gluten-Free a Good Idea?

Diagnosed with inflammatory bowel disease (IBD) in her teens, Varda Meyers Epstein always thought fiber caused her digestive problems until she tried a ketogenic, gluten-free diet.

“I had applied through my health fund to have bariatric surgery because I felt hopelessly overweight. Then a neighbor urged me to give a low-carb, high-fat diet a chance,” says Meyers Epstein, 57, a writer in Efrat, Israel.

Adopting a ketogenic diet, she lost 60 pounds in six months — but that wasn’t the only change: “My severe flatulence left me. When I dramatically lowered carbs in my diet, fiber stopped bothering me. My stomach distress had always been about grains and sugar, apparently. I can now eat salads.”

Going gluten-free for IBD

Almost one in five IBD patients tries a gluten-free diet, according to a study from the University of North Carolina (UNC) at Chapel Hill. Of those who do, two-thirds report improved symptoms and 38 percent report fewer or less-severe flare-ups between periods of remission. This was the largest study of the gluten-free diet in patients with IBD, including a total of 1,647 participants. Among these, 314 had tried the gluten-free diet while 135 continue following it, or about 9 percent. The data were drawn from a larger internet-based study of 15,000 patients collected by the Crohn’s & Colitis Foundation. Crohn’s disease and ulcerative colitis both fall under the IBD umbrella (see below).

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IBD defined

Crohn’s disease and ulcerative colitis are inflammatory bowel diseases (IBD) that cause chronic inflammation and damage in the gastrointestinal (GI) tract. IBD affects as many as 3 million Americans, according to the Crohn’s & Colitis Foundation. The national annual financial burden is estimated at $31 million.

Crohn’s disease

Crohn’s disease can affect any part of the GI tract from the mouth to the anus. It most commonly affects the end of the small intestine (the ileum) where it joins the beginning of the colon. Crohn’s disease may appear in patches affecting some areas of the GI tract while leaving other sections completely untouched. Inflammation may extend through the entire thickness of the bowel wall.

Ulcerative colitis

Ulcerative colitis is limited to the large intestine (colon) and the rectum. The inflammation occurs only in the innermost layer of the lining of the intestine. It usually begins in the rectum and lower colon but may also spread continuously to involve the entire colon.
For more information, visit crohnscolitisfoundation.org.
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Animesh Jain, MD, associate professor of medicine at UNC, did not work on the study but says it is valuable because of its size. “It also reports patient-reported outcomes, which we are factoring more and more into clinical practice,” he explains.

“But that is not the end-all of treatment for IBD,” Jain says. “Both Crohn’s disease and ulcerative colitis lead to structural inflammatory damage to the bowel, which can include redness of the lining, deep ulcers and complications like blockages of the intestines. When I’m treating somebody with IBD, their symptoms are an important part of what’s going on, but the other piece of the story is: How does their bowel look?”

Bowel healing can only be assessed by clinical tests. Like celiac, IBD is an autoimmune disease with no known cure. Unlike the link between gluten and celiac, specific environmental causes of the inflammation remain unknown.

“Unfortunately, we don’t have great research for any specific diet that will either prevent the disease from starting or ameliorate the inflammatory disease once it starts,” Jain says.

Current research

A large multicenter study now underway is investigating two diets that might relieve symptoms of Crohn’s disease. It includes the Specific Carbohydrate Diet, which is low in complex carbohydrates, and the Mediterranean diet. For now, doctors typically do not prescribe dietary changes as a frontline treatment.

“Usually when we see patients in the clinic, they are quite ill,” Jain says. “They have active inflammation, which can lead to intense diarrhea, bleeding, weight loss or other complications. In that situation, we usually rely on more potent, traditional pharmacologic therapy.”

Trigger foods

Once IBD is controlled, many patients manage it by identifying trigger foods and eliminating them during flare-ups. Difficult-to-digest foods can include insoluble fiber, nuts, seeds, and raw fruits and vegetables.

Ines Pinto-Sanchez, MD, assistant professor of medicine in gastroenterology for the Michael G. DeGroote School of Medicine at McMaster University in Hamilton, Canada, says the UNC study highlights another problem: Many people attempt a gluten-free diet, experience improved symptoms and then attribute gluten as their trigger. “ does not necessarily mean they will remain without symptoms or that it will lead them to remission. What is lacking is studies evaluating the real effect of a gluten-free diet in IBD.”

This can lead patients to stick with a gluten-free diet despite recurring IBD symptoms, which Pinto-Sanchez says she would not encourage.

A celiac–IBD link?

A possible overlap between celiac and IBD may be obscuring the evidence. A few studies have looked for an increased prevalence of both diseases in the same patients. Results vary widely. An Australian meta-analysis published this year pooled all the data for more conclusive results. It found a slightly higher risk for celiac among IBD patients. Conversely, the rate of IBD among celiac patients was 11 times higher than in the general population.

Pinto-Sanchez says the link isn’t surprising because both conditions involve immune reactions. “What is not very well known and clear in those studies is whether gluten-free diets will have the same effect in IBD as in celiac disease,” she says.

If an IBD patient sees improvement on a gluten-free diet, Jain says, “It would be relevant to formally test the patient for celiac disease because that would obviously be a major change in how we treat them. If we’re treating both Crohn’s disease or ulcerative colitis and celiac disease in the same patient, that adds important implications.”

Kelly Issokson, RD, of Cedars-Sinai medical center in Los Angeles, agrees. “If my patient is interested in starting a gluten-free diet, I recommend first getting tested for celiac disease before going gluten free,” she says. “Testing for celiac has many benefits, including helping the patient understand how strict they need to be on a gluten-free diet.”

The role of FODMAPS

Issokson says benefits of a gluten-free diet might not relate directly to gluten: “Gluten-containing foods are also a significant source of fructan, a type of FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols), which has been associated with functional gastrointestinal symptoms in irritable bowel syndrome and IBD.”

Recent analysis by Chinese researchers found IBD patients on a low-FODMAP diet showed significant improvement in multiple symptoms.
“Thus, a short-term, low-FODMAP diet or even a diet with a reduction in fructans may be a better choice and lead to symptom improvement without the need to follow a long-term gluten-free diet,” says Issokson.

Pinto-Sanchez says she would not advise any IBD patient who is in remission and doing well to try a restrictive diet. “The gluten-free diet is not benign. It can lead to nutritional deficiencies,” she notes.

“For symptom management, I educate patients about the importance of a balanced diet for gut healing and overall health, about foods and eating behaviors that commonly contribute to gastrointestinal symptoms, and about the role of physical activity and stress reduction in helping to manage them,” Issokson says. “Restricted diets can decrease quality of life, increase risk for malnutrition and slow the healing process. My goal is to help achieve nutritional balance through the least restrictive diet possible.”

Gluten free with colitis

After Kat Leffler, 55, started having digestive symptoms, she was diagnosed with colitis. A freelance consultant and copywriter in Omaha, Nebraska, she questioned the diagnosis and concluded she was gluten-sensitive but could not persuade doctors to investigate.

When she first reported stomach complaints to her doctor in September 2014, she was given FODMAP and DASH diet brochures. Three months later, she landed in the emergency room (ER) with cramps, no bowel movements and vomiting. She was diagnosed with colitis and, over several ER visits, prescribed drugs to treat infection and symptoms.

“I already had suspicions about commercial food production, and this led me to the Paleo practice,” says Leffler. “It is entirely gluten and grain free. This was hard. It was almost impossible to eat out anywhere that would be compliant. In the beginning, I didn’t have many recipes or ideas, so it was also boring.”

After 90 days and again after 180 days of clean eating to reset her immune system, she would try a slice of pizza or two and end up back in the ER. She identified grains and legumes as primary irritants, while dairy affects her respiratory system. In 2016, she went to a gastroenterologist, who gave a full battery of tests. The doctor placed her on the spectrum between irritable bowel syndrome and IBD, closer to the IBD end. Again she received FODMAP and DASH diet brochures, “neither of which are gluten-free eating,” says Leffler.

When she raised her concern about gluten sensitivity, the doctor dismissed it by telling her that “everybody says they have a gluten issue these days,” Leffler recalls.

She still follows a gluten-free diet pretty strictly: “I have to if I want to function.”

Gluten free with Crohn’s disease

Heather Sliwinski, 32, began having symptoms in 2010. The San Francisco public relations professional went through a few doctors and many different tests leading to a diagnosis of Crohn’s disease in 2013. Sliwinski says she went gluten free in 2011 after a year of symptoms, without support from any doctors.

“In the three-year gap between the onset of Crohn’s and diagnosis, I felt helpless. I wasn’t getting any answers, but I also wasn’t getting any suggestions on ways to improve my symptoms. I wanted to take my health into my own hands and do anything to relieve my gut issues,” says Sliwinski.

On the Specific Carbohydrate Diet, which removes complex carbohydrates including gluten, her symptoms continued to improve without medication. After a year on the diet and trying a new gastroenterologist, she had a second colonoscopy. Her intestines looked healthy and without inflammation compared to one a year earlier that showed indeterminate microscopic colitis.

Sliwinski says, “The new doctor supported my diet and was very interested in its effect on IBD from her own research perspective.”

She recalls, “After being gluten free and grain free, I was slowly able to add raw fruits and veggies back into my diet, which are notoriously hard for IBD patients to tolerate. Seven years later, I am still strictly gluten free, lactose free, and avoid many grains and sugars. I am not on any medication specifically to treat Crohn’s and can tolerate a much wider range of foods.”

Sliwinksi says she has no plans to ever eat gluten again: “I remember what life was like before I made these dietary changes. I would never go back to the pain, the numerous trips to the bathroom, the fatigue and the anxiety just to eat a slice of bread.”

Van Waffle is a freelance journalist in Waterloo, Canada, and research editor for Gluten-Free Living. He blogs at vanwaffle.com.

Learn more about the health and medical experts who who provide you with the cutting-edge resources, tools, news, and more on Gluten-Free Living.
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Gluten and inflammatory bowel disease (IBD)

Gluten and IBD

Many people with IBD (both Crohn’s disease and ulcerative colitis) avoid gluten from their diet after finding it is a ‘trigger’ food for them.

There are various reasons as to why this may be:

  1. You may have undiagnosed coeliac disease. Coeliac disease is an autoimmune condition – and so is inflammatory bowel disease. If you have one autoimmune condition then you are more likely to have another. A study in 2011 also showed that people with Crohn’s disease are more genetically predisposed to coeliac disease2.
  2. You have undiagnosed gluten allergy or sensitivity
  3. You have leaky gut syndrome and gluten is contributing to it. Leaky gut is a condition in which the small intestine membrane has become porous (or leaky) allowing toxins, microbes, undigested food particles and antibodies to pass through and travel around your body in your bloodstream. If people are sensitive to gluten then the delicate intestinal membranes can be irritated by gluten which can contribute to leaky gut. Symptoms of leaky gut include bloating, gas, cramps, food sensitivities and aches and pains. It has also been linked with conditions such as eczema, inflammatory arthritis and chronic fatigue
  4. The wheat that we are eating today is different from the wheat our grandparents ate (and their grandparents before them). We have developed wheat to be more hardy when it’s growing. This means that around 5% of the proteins found in our wheat today are new and our guts may not have adapted to processing them which could cause some people problems

Many people with IBD have tried cutting gluten out of their diets. A cross-sectional study3 in the United States in 2014 found “65.6% of all patients, who attempted a gluten-free diet, described an improvement of their gastrointestinal symptoms and 38.3% reported fewer or less severe IBD flares. In patients currently attempting a gluten free diet, excellent adherence was associated with significant improvement of fatigue”.

Recently, at United European Gastroenterology (UEG) Week 2016 – held in October 2016 in Vienna – researchers presented findings from a study into a family of proteins in wheat. The researchers said that amylase-trypsin inhibitors (ATIs) – have been shown to trigger an immune response in the gut that can spread to other tissues in the body. They say ATIs have been suggested to exacerbate rheumatoid arthritis, multiple sclerosis (MS), asthma, lupus, and nonalcoholic fatty liver disease, as well as inflammatory bowel disease4.

If you decide to eliminate gluten and/or wheat from your diet it should be done under the guidance of a dietician and it is important to cut it 100% from your diet for at least 30 days. If you are sensitive to gluten then even a tiny amount of it could cause an immune response which could trigger the symptoms you were experiencing. If you find that there is no change in your symptoms then you may not be sensitive to gluten and can reintroduce it.

When some people stop gluten they find that they go through a period of ‘gluten withdrawal’ which can cause symptoms such as brain fog, stomach ache, headaches, dizziness. These symptoms are temporary as your body adapts (and may indicate that you have a sensitivity to gluten).

When first going gluten free many people just switch their normal products for the gluten free versions of products. It is important to bear in mind that these products are highly processed and are not necessarily nutritious. Some people also feel worse from eating them due to some of the ingredients used in them (such as additives and grains).

Going gluten free can seem overwhelming at first, but you will quickly learn what healthy substitutes you can make for your favourite foods and how to cook gluten free. Visit our recipe section for some inspiration.

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