Recently I attended a conference where one of the presenters mentioned that she thinks it’s malpractice for healthcare practitioners to have all of their patients go gluten free without first testing for Celiac disease. While I recommend for my patients to avoid gluten while restoring their health, I don’t require all of my patients to obtain a Celiac panel, and I’ll discuss some of these reasons in this blog post. However, the presenter did make some valid points, which I’ll also talk about. And so the goal of this blog post isn’t to convince you to order a Celiac panel (assuming you haven’t done so already), but only to provide you with information to help you make an informed decision.
What I’m going to do is first list some of the reasons why everyone with an autoimmune thyroid condition should consider doing a Celiac Panel. I will then list some reasons why it might not be a good idea for everyone with Graves’ Disease and Hashimoto’s to do a Celiac panel. This way you will see both perspectives. I’ll then talk about the different testing options for determining if you have Celiac disease or a non-Celiac gluten sensitivity. Finally, for those who choose to go through the testing, I’ll discuss the approaches you should take if you test positive or negative for a gluten sensitivity.
Reasons Why Everyone With Thyroid Autoimmunity Should Consider Doing a Celiac Panel
1. Celiac Disease is more common in those with thyroid autoimmunity. I discussed this in a separate article entitled “Celiac Disease and Thyroid Health [1]”. In the article I discussed how studies show that both those people with Graves’ Disease and Hashimoto’s Thyroiditis have a greater chance of developing Celiac disease. In fact, some people develop Celiac disease first, and then years later they will develop an autoimmune thyroid condition. But assuming someone with either Graves’ Disease or Hashimoto’s hasn’t been diagnosed with Celiac disease and hasn’t had any testing done to confirm this, due to the higher prevalence it makes sense to get a Celiac panel. Those with other types of autoimmune conditions also have a greater chance of developing Celiac disease, and therefore they also might want to consider obtaining a Celiac panel.
2. If someone tests positive for Celiac disease they will need to avoid gluten on a permanent basis. Regardless of whether someone has overt symptoms when consuming gluten, if a person tests positive for Celiac disease then they will want to avoid gluten on a permanent basis. Not doing so can not only prevent their autoimmune thyroid condition from going into remission, but there are other risks of untreated Celiac disease, including the following (1) [2]:
- Iron deficiency anemia [3]
- Early onset osteoporosis or osteopenia
- Infertility and miscarriage
- Vitamin and mineral deficiencies
- Central and peripheral nervous system disorders
- Pancreatic insufficiency
- Gallbladder issues
3. It’s best to find out if someone has Celiac disease sooner than later. Why is it best to find out if a person has Celiac disease sooner than later? Because if someone has Celiac disease then they need to completely avoid gluten, and so it does make sense to find out sooner than later to make sure you do everything you can to avoid gluten.
4. You can’t rely on symptoms alone. Although most people with Celiac disease will experience overt symptoms upon consuming gluten, this isn’t the case with everyone. In fact, some people have silent Celiac disease, which is when they don’t experience overt symptoms, yet test positive for the markers of Celiac disease. When this is the case the person should avoid gluten on a permanent basis, even if they feel fine when consuming gluten.
Reasons For NOT Testing Everyone For a Celiac Panel
1. If someone has been gluten free for awhile this test won’t be accurate. One of the downsides of testing for Celiac disease, or any other testing for gluten antibodies, is that you need to be eating gluten for the test to be positive. The reason for this is because for those who have Celiac disease, eating gluten will cause the immune system to produce certain antibodies, and these antibodies are measured during the testing. If the person hasn’t eaten gluten for a few weeks, or perhaps even a few months, then there still can be detectable antibodies on such a test. However, if the person has been completely gluten free for a prolonged period of time then such testing will come out negative, even if the person has Celiac disease.
2. Some people are fine giving up gluten forever even without a diagnosis. Another reason not to test everyone for Celiac disease is because some people have no problem avoiding gluten on a permanent basis, even if they haven’t confirmed that they have Celiac disease. This is especially true for those who feel better when avoiding gluten. However, I mentioned earlier how not everyone with Celiac disease experiences symptoms when consuming gluten. In my experience, patients are less likely to give up gluten on a permanent basis if they don’t experience any noticeable symptoms when eating gluten. However, if someone tests positive for Celiac disease or a non-Celiac gluten sensitivity, they are more likely to give up gluten on a permanent basis, even if they don’t experience any negative symptoms when consuming gluten.
3. A negative Celiac panel doesn’t always rule out Celiac disease. Although it would be great if such testing was 100% accurate, this isn’t always the case. Here are some of the factors which can lead to a false-negative test result (2) [4]:
- Age of less than 2 years
- Laboratory error
- Reduction or elimination of gluten from the diet
- Selective IgA deficiency
- Use of corticosteroids or immunomodulating drugs
So if an adult is eating gluten regularly, an IgA deficiency has been ruled out, and if they aren’t taking corticosteroids or immunomodulating drugs, then how can they tell if this is a false negative? Well, if Celiac disease is suspected in this situation even if someone has negative test results, one option is to have them get a biopsy of the small intestine. In addition, they can test for the genetic markers of Celiac disease, which are HLA-DQ2 and HLA-DQ8. If the Celiac panel is negative and both of these genetic markers are also negative then chances are the person doesn’t have Celiac disease.
4. A negative Celiac panel doesn’t rule out a non-Celiac gluten sensitivity. It’s possible to not have Celiac disease, yet have a sensitivity to gluten. I’m not going to get into detail about this here, as you can read my article on Celiac disease and Thyroid heath for more information. The good news is that there is more comprehensive testing available for gluten, which I’m about to discuss next.
What Are The Different Testing Options For Gluten?
There are numerous testing options to determine if someone has Celiac disease, or a non-Celiac gluten sensitivity. Here are some of the main options:
Gliadin antibodies. Gliadin is a protein of gluten, and while this is part of a Celiac panel, the reason why I listed this marker alone is because many healthcare professionals will only test this single marker. While elevated gliadin antibodies will confirm that you have a gluten sensitivity (not necessarily Celiac disease), a negative finding doesn’t rule out either Celiac disease or a non-Celiac gluten sensitivity. With that being said, patients with Celiac disease are more likely to have positive gliadin IgA antibodies, while those with non-Celiac gluten sensitivity are more likely to have positive gliadin IgG antibodies (3) [5].
Celiac panel. Unfortunately there isn’t a single Celiac panel available. For example, if you visit the Labcorp website and do a search for “Celiac tests”, you’ll notice a few different options. All of the panels will test for the IgA and IgG deamidated gliadin antibodies, along with tissue-transglutaminase IgA and IgG. In addition, most panels will test for immunoglobulin A as well, which will help to rule out a false negative result. Some panels will also test for the endomysial antibodies, although many medical doctors will test for only the gliadin and transglutaminase antibodies. In my opinion, the more comprehensive the panel, the better.
Intestinal biopsy. An intestinal biopsy is still recommended by some gastroenterologists to diagnosis Celiac disease. However, it’s debated whether a biopsy is required to confirm the diagnosis of this condition. If the person is presenting with the signs and symptoms of Celiac disease and has a positive Celiac panel, then there’s a very good argument that a biopsy isn’t necessary. On the other hand, if the person presents with signs and symptoms indicative of Celiac disease, yet the Celiac panel comes back negative, then this might be a good time to conduct an intestinal biopsy.
Cyrex Labs Wheat/Gluten Proteome Reactivity And Autoimmunity (Array #3). This is the most comprehensive test available for determining if someone has a gluten sensitivity. This test measures the antibody production against multiple wheat proteins and peptides, transglutaminase-2, 3, and 6, and the gliadin-transglutaminase complex. Although Cyrex Labs claims that this test isn’t diagnostic of Celiac disease, many times it can give a pretty good indication if someone has this condition, or a non-Celiac gluten sensitivity.
Enterolabs gluten sensitivity stool test. This is also a pretty good test, although it’s not as comprehensive as the one from Cyrex Labs. The reason I listed this here is because it’s a popular test, and over the years I have had numerous patients order this test prior to working with me.
Genetic testing. When combined with a negative Celiac panel, genetic testing can help to exclude Celiac disease. The genetic markers associated with Celiac disease include HLA-DQ1 and HLA-DQ8. Approximately 0.4% of patients with Celiac are both HLA-DQ2 and HLA-DQ8 negative (4) [6]. But as mentioned earlier, if someone has been eating gluten and has a negative Celiac panel, and also has both genetic markers negative, then there is a very high probability that they don’t have Celiac disease. Genetic testing can also be considered if someone has been following a gluten free diet for a prolonged period of time, as one doesn’t have to be eating gluten for the results to be accurate.
What Approach Should You Take If You Test Positive For A Gluten Sensitivity?
If you choose to get one or more of the tests I listed above and it comes out positive, should you avoid gluten on a permanent basis? Or is eating a small amount of gluten every now and then okay? Well, some will argue that anyone with Graves’ Disease or Hashimoto’s Thyroiditis (or any other autoimmune condition) should avoid gluten on a permanent basis regardless of what the test results show. And one of the main reasons for this is because regardless of whether someone has a gluten sensitivity or not, the research shows that gluten causes a leaky gut in everyone. And for this reason alone, a good argument can be made that anyone with an autoimmune condition who tests positive for Celiac disease, or a non-Celiac gluten sensitivity, should ideally avoid gluten on a permanent basis.
In fact, someone with a confirmed case of Celiac disease should even be cautious about eating certain packaged gluten free foods. And there are a few reasons for this. First of all, gluten free foods aren’t always 100% gluten free, as they can include less than 20 ppm of gluten, yet some people react to as little as 5 ppm. In addition, some “so-called” gluten free foods have greater than 20 ppm of gluten, and so if you do choose to eat packaged gluten free foods, please make sure they are certified gluten free. For more information on this I would visit the websites for the Gluten-Free Certification Organization [7] and Beyond Celiac [8].
In addition, if you test positive for a gluten sensitivity you also need to be cautious when eating out. And the reason for this is because if you suspect that a food is gluten free, or even if it’s labeled as being gluten free on the restaurant menu, cross contamination is common.
What Approach Should You Take If You Test Negative For A Gluten Sensitivity?
As I mentioned earlier, there is always the chance of a false negative result. I also mentioned that if you suspect Celiac disease but if the Celiac panel comes back negative then you can consider obtaining an intestinal biopsy. But perhaps a better, less non-invasive option is to order the genetic markers of gluten, HLA-DQ2 and HLA-DQ8.
Just keep in mind that a negative intestinal biopsy doesn’t rule out a non-Celiac gluten sensitivity, and the same is true if someone tests negative for the genetic markers associated with Celiac disease. But even if you’re 100% confident that you don’t have Celiac disease or a non-Celiac gluten sensitivity, it is a good idea to minimize your consumption of gluten. Not only is gluten unnecessary to consume, but as I mentioned earlier, even if you’re not sensitive to gluten, it can cause a leaky gut, which is theorized to be a factor in everyone with Graves’ Disease or Hashimoto’s Thyroiditis.
In summary, many people with autoimmune thyroid conditions such as Graves’ Disease and Hashimoto’s Thyroiditis should consider doing a Celiac panel. The reason for this is because Celiac disease is more common in thyroid autoimmunity, and if someone has Celiac disease they need to avoid gluten on a permanent basis. Also remember that you can’t rely on symptoms, as while most people with Celiac Disease will experience overt symptoms when consuming gluten, this isn’t always the case. Just keep in mind that you need to be eating gluten for a Celiac panel to be accurate. Also, a negative Celiac panel doesn’t always rule out Celiac disease, and it’s also possible to have a non-Celiac gluten sensitivity. An intestinal biopsy is also recommended by some gastroenterologists to diagnose Celiac disease, and Cyrex Labs has a comprehensive test that can help determine if someone has a gluten sensitivity.