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Joint pain and inflammation can be common symptoms for the estimated 3 million adults and children in the U.S. who have celiac disease (CD) and possibly for millions more who may be sensitive to gluten. But what if you have arthritis? Will a gluten-free diet help? Doctors are still debating this point, but some experts say it might.
Like many types of arthritis, celiac disease is an autoimmune disease. With these disorders, the immune system mistakenly attacks healthy tissue instead of viruses, bacteria and other pathogens. In people who have CD, gluten – a complex of proteins found in grains such as wheat, barley and rye – triggers a powerful autoimmune response that damages the small intestine and affects its ability to absorb nutrients. This can lead to gastrointestinal symptoms, such as diarrhea, abdominal pain and bloating.
Alessio Fasano, MD, who directs the Center for Celiac Research at Massachusetts General Hospital in Boston, says people who are sensitive to gluten can have symptoms anywhere in the body when partially digested gluten fragments leak from the intestine into the bloodstream.
“Unlike other proteins, we don’t digest gluten completely,” he explains. “In some people, the immune system sees gluten as the enemy and will unleash weapons to attack it, causing inflammation in the intestines as well as in other organs and tissues.”
This can cause serious problems outside the gut, including weight loss, anemia, osteoporosis, infertility and miscarriage, skin rashes, headache, depression, fibromyalgia and joint pain. This is partly due to inflammation and partly due to poor absorption of vital nutrients.
Getting a CD Diagnosis
Celiac disease is diagnosed with a blood test that looks for antibodies to gluten. Antibodies are protein produced by the body’s immune system when it detects harmful substances. If the test is positive, it’s followed by an endoscopic biopsy to check for small intestine damage.
“The inside of a healthy small bowel resembles a deep-pile carpet, but in untreated celiac disease, it looks like a tile floor,” explains Joseph A. Murray, MD, who directs the Celiac Disease Program at Mayo Clinic’s campus in Minnesota. CD damages villi – finger-like protrusions that aid in the absorption of nutrients from the small intestine – and prevents them from doing their job.
Although awareness of CD has never been greater, it remains underdiagnosed. One reason is that CD symptoms are subtle and can look like many other things, from irritable bowel syndrome and migraines to arthritis. Another is that a growing number of people with CD don’t experience classic gut problems, and a few with severe intestinal damage have no clinical symptoms at all. These days, it can take five to seven years for some patients with celiac disease to be diagnosed – down from an average of 10 years just a short while ago.
Dr. Murray says rheumatoid arthritis, type 1 diabetes and other autoimmune disorders are red flags that should alert doctors to test for CD because having one autoimmune disease increases the likelihood of having another. A few studies have shown that people with Sjogrens syndrome, psoriatic arthritis and lupus may also have an increased likelihood of having celiac disease. Dr. Murray encourages people with autoimmune conditions to talk to their doctor about being screened for celiac disease or gluten sensitivity.
Gluten Sensitivity: Fact or Fad?
Less is known about gluten sensitivity. According to Rochelle Rosian, MD, a rheumatologist at Cleveland Clinic, people who are gluten sensitive have a different type of immune response to grain proteins. They don’t develop antibodies to gluten or have small intestine damage, but they do have CD symptoms, especially outside the gut. There is no test for gluten sensitivity, which has created skepticism among some doctors.
“There is controversy among experts and in the literature as to whether non-celiac gluten sensitivity actually exists,” says Maria Vazquez Roque, MD, a gastroenterologist at Mayo Clinic, who is studying the relationship between leaky gut and gluten sensitivity. “But many in the medical community consider patients to have gluten sensitivity when celiac disease and wheat allergy [a reaction to all proteins in wheat, not just gluten] have been ruled out and symptoms improve on a gluten-free diet.”
Gluten as Joint Pain Trigger
According to Dr. Rosian, inflammation outside the gut is especially likely to affect the joints. She adds that many of her RA patients who are sensitive to gluten notice less joint pain when they don’t eat it.
“Patients with arthritis are always looking for nondrug ways to manage inflammation,” she says. “We know that certain foods are pro-inflammatory and that includes gluten-containing grains and the thousands of foods made from them. When some, but not all, people with celiac disease or gluten sensitivity eliminate these from their diet, they find their arthritis improves.”
No Grain. No Pain?
Medical experts caution that it’s important not to try a gluten-free diet for arthritis before testing for celiac disease because the test won’t be accurate. And sometimes the problem isn’t gluten.
“Maybe it’s a wheat or lactose allergy or an issue with FODMAPs [small sugar molecules in some fruits and vegetables]. These can be pro-inflammatory and irritate the gut lining,” Dr. Rosian says.
For people with celiac disease or gluten sensitivity, however, a gluten-free diet isn’t a fad – it’s medicine.
The only treatment for diagnosed CD and gluten sensitivity is a gluten-free diet. “For patients with celiac disease, gluten-free isn’t a fad, it’s a medical necessity,” Dr. Fasano says. It is also effective. Many people, including those with gluten-related joint pain, may notice improved symptoms within weeks. For others, it may take longer, and some may never find relief. But experts say it’s definitely worth talking to your doctor about being screened for CD if you have RA, type 1 diabetes or any other autoimmune disorder.
Dr. Murray, coauthor of the American College of Gastroenterology’s guidelines on the diagnosis of celiac disease, encourages people with autoimmune conditions to talk to their doctor about being screened for celiac disease and gluten sensitivity. Patients must be heeding Dr. Murray’s advice and physicians must be heeding the advice in the guidelines, because experts at the Celiac Disease Center at Columbia University in New York City say most of their referrals come from rheumatologists and endocrinologists.