Food and Food Intolerances
We all know that food is indispensable to life as it provides the substances needed for normal growth and development and even for maintaining our daily activity. However, they can only be used by the body once they have been digested and absorbed by the digestive tract: digestion and absorption are therefore fundamental functions for the maintenance and well-being of the individual.
However, there are some people who cannot tolerate certain foods because when they are ingested and come into contact with the intestinal mucosa, they trigger more or less violent reactions that cause damage and disrupt its normal functioning, particularly with regard to digestion and absorption. This is called FOOD INTOLERANCE, which can be against fish, shellfish, milk, etc. and can manifest itself over a longer or shorter period of time.
When a situation of this kind relates specifically to GLUTEN and manifests itself in a permanent and definitive way, it can be said to be a CELL DISEASE.
Gluten
Wheat grain, like other cereals, has a complex structure which includes many substances, not all of which are harmful to the coeliac’s intestine. The pericarp and germ are generally utilised in the flour production process, making up what is commonly known as the bran. Naturally, this is not where we will find the culprit of the disease.
As far as the endosperm is concerned, on the one hand we have to consider the starch (which is completely innocent in this process!), and on the other, a large group of proteins with different physical and chemical characteristics. In this group, we can distinguish between those that dissolve in water (albumins and globulins) and those that don’t. This is the group of insoluble proteins.
It is the insoluble proteins that are generically known as GLUTEN and it is from this that various fractions with harmful effects for coeliacs have been isolated. In practice, however, it is only gluten that interests us. Its “aggressiveness” depends on its composition and as this is not the same in all cereals, they are tolerated differently: So while wheat, rye and barley have to be completely removed from a coeliac’s diet, other cereals such as maize and rice are perfectly harmless. However, this is not generally accepted and so it will be placed here alongside the other offending cereals.
Celiac Disease
When a coeliac’s intestine has to endure an unrestricted diet, the gluten in the cereals they normally eat will cause changes so profound that they prevent the normal utilisation of food and lead to the appearance of symptoms. If the gluten is removed, these changes disappear and everything returns to normal… as long as the patient keeps to the diet!
This disease can appear at any age as long as gluten has already been included in the diet. It usually appears in the second or third half of life (between 6 and 20 months of age), a few months after the introduction of flour into the diet (porridge, bread, biscuits, etc.). The child starts to lose their appetite, stops gaining weight, becomes sad and irritable, bowel movements start to become more frequent, soft and voluminous (diarrhoea) and the abdomen (the “belly”) becomes more protruded and distended. If the diagnosis is not made and the diet instituted, the situation worsens and the child sometimes reaches a state of severe malnutrition. In a small number of cases, the symptoms are different: sometimes there’s just repeated vomiting, abdominal pain of varying intensity, constipation or just unexplained growth retardation.
These are situations that only an experienced doctor associates with coeliac disease and which can take a long time to diagnose. For reasons we don’t know, the manifestations of the disease are generally more intense in the first few years of life and then tend to diminish in intensity. Thus, in older children and adolescents, dietary failures often don’t lead to diarrhoea and the patient continues to feel well. As we have already seen, this can lead to treatment being abandoned.
Unfortunately, there is no cure for coeliac disease, so the reintroduction of gluten into the diet will sooner or later lead to the reappearance of certain symptoms: anaemia, a slight increase in the volume of the abdomen, a drop in school performance, growth arrest, absence or disturbance of menstruation and, in adults, reduced fertility or even sterility. It must therefore be emphasised that once the diagnosis has been established with certainty, THE DIET MUST BE COMPLIANT FOR LIFE.
What is not yet perfectly clear is why only some people are gluten intolerant and develop the disease. Naturally, factors related to the individual’s diet come into play here, which may go some way to explaining why this pathology does not exist in Eastern countries where wheat is not the staple diet.
Today, however, there is no doubt that there is a clearly transmitted hereditary predisposition, since families of coeliacs have a much higher number of patients than would be expected in the general population. Studies have calculated that the risk of the disease reappearing after the first case in a parent or sibling is around 10 times greater. When the disease is present in distant relatives, this risk is much lower. It is probably the combination of these two types of factors that creates the favourable environment for the disease to appear. It seems to correspond to a disturbance in the body’s defence system which, as a result, reacts abnormally to dietary gluten, thus causing changes in the intestinal mucosa and, ultimately, the onset of symptoms.
Celiac disease: A long but interesting story
Around 10,000 years ago, people realised that it was possible to sow the land and obtain crops of cereals such as wheat. From then on, their yield was such that they were able to live in the same place without having to constantly search for food. One consequence of this discovery was civilisation, another was the risk of having coeliac disease!
In the 2nd century, a Greek, Aretaeus of Cappadocia, described patients with a certain type of diarrhoea using the word “Koiliakos” (those suffering from the intestine). It seems that even then he was referring to what Samuel Gee, a London doctor, observed in children and adults in 1888 and called “coeliac disease”, also using the Greek term. In his writing, Gee predicted with great intuition that “controlling the diet is the main part of the treatment…the intake of farinaceous foods must be reduced…and if the patient can be cured, it must be through diet”.
In the years that followed, several doctors, particularly paediatricians, dedicated themselves to observing and trying to understand the causes of this disease, although little progress was made. During the Second World War, food rationing imposed by the German occupation drastically reduced the supply of bread to the Dutch population. Prof Dicke, from Utrecht, then realised that children with “coeliac disease” got better despite the severe shortage of food. He associated this with the low cereal content of the diet.
This association was later confirmed in Birmingham by Charlotte Anderson and laboratory work finally showed that wheat and rye contained the substance that causes the disease: gluten! J.W. Paulley, an English doctor, had meanwhile observed in a coeliac who had undergone surgery that his intestinal mucosa did not have the usual appearance; this fact, confirmed by other researchers, was extremely important as these changes would now allow a diagnosis to be made on a firm basis.
The importance of this discovery increased when, in the 1950s, an American officer, Crosby, and an engineer, Kugler, developed a small device with which intestinal biopsies could be taken without having to operate on the patient. This device, the Crosby capsule, is still used today, with minor modifications, to diagnose coeliac disease.
Over time this disease has been called many different things, such as celiac disease, gluten-sensitive enteropathy, celiac sprue, non-tropical sprue, etc. All these names refer to the same condition but some of them were used by researchers who were convinced that it was a different problem.
To put an end to this state of affairs, in 1969 the European Society for Paediatric Gastroenterology and Nutrition (ESPGAN) proposed a number of criteria that would allow for correct diagnosis and treatment. Thus, when we talk about coeliac disease, we are referring to a situation of permanent intolerance to gluten that is accompanied by more or less characteristic lesions in the intestine, lesions that improve when gluten is removed from the diet and worsen again when it is reintroduced.