In a perfect world, every patient with celiac disease would diligently follow a completely gluten-free diet, without a speck of gluten to cause intestinal damage and associated symptoms. Unfortunately, gluten is nearly impossible to avoid entirely. It is also true that not every patient is strict about the diet, as it can be difficult, costly, and burdensome to follow. However, even those who take the diet quite seriously often continue to experience notable symptoms. Researchers Syage, Kelly, et al. decided it was time to try to determine just how much gluten celiac disease patients might be ingesting, be it deliberately or accidentally.
A typical adult without celiac disease consumes between 5 and 15 grams of gluten per day. Those with celiac disease are advised to eliminate gluten entirely; even levels as low as 50mg/day can cause difficulties for some patients. Using data available from related studies, the researchers sought to estimate the daily gluten consumption of celiac disease patients.
Three methods were used to estimate gluten consumption. Methods one and two involved measuring the amount of gluten immunogenic peptides (GIPs) in stool samples and urine samples. GIPs are bits of the gluten molecule that are unable to be digested, passing through the body’s digestive system instead. Method three involved analysis of subjects involved in two clinical trials for a celiac disease-related medication. In one trial, individuals were put through controlled gluten challenges. In another trial, they were told to maintain their normal gluten-free diet, but in fact, during the treatment phase, they eliminated more than their usual amount of gluten. The changes to the intestine allowed for calculation of how much additional gluten they removed from their typical diet.
None of the methods were ideal. The researchers noted a variety of limitations, including test instrument sensitivity, the speed at which digestion occurred, and the “trial effect” of patients modifying their adherence to a gluten-free diet just because of participating in a clinical trial.
Overall, the researchers estimated that typically, celiac disease patients who suffer from recurrent symptoms while on a gluten-free diet (about 30% of all patients on a gluten-free diet), consume upwards of 244mg of gluten per day. While this is a tiny fraction of the amount ingested with a standard diet, it is certainly enough to cause continued symptoms in patients with celiac disease (CD).
“It is well recognized,” stated Jack A. Syage, PhD, CEO of ImmunogenX, and first author of the study, “that adherence to a gluten-free diet (GFD) is certainly impractical and nearly impossible to achieve. However, until this analysis, involving the measurement of gluten in urine and stool samples of CD patients, there was little basis for estimating the amount of gluten that sneaks into a GFD. The new results indicate that it is not unusual for CD patients to consume hundreds of milligrams of gluten on a given day where less than 50 mg/day is considered a safe level.”
The results from this study indicate that a portion of the celiac disease population experiences difficulty managing a strict, gluten-free diet. The small amount of gluten that patients could be exposed to on a daily basis is sufficient to trigger symptoms and may even contribute to intestinal damage.
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