In this article
- Understanding celiac disease / what is celiac disease?
- What are the signs and symptoms of celiac disease?
- Diagnosis and screening for celiac disease
- What about non-celiac gluten sensitivity?
- Treating celiac disease and non-celiac gluten sensitivity
- What is the connection between celiac disease and Hashimoto's disease?
- Treating celiac disease and Hashimoto's
- Should you eat gluten if you have Hashimoto's disease?
If you have autoimmune thyroid disease, you are likely aware of a connection between celiac disease and gluten intolerance. There's a strong association between Hashimoto's thyroiditis, hypothyroidism, Graves' disease, and celiac disease. Patients with any of these conditions must understand celiac disease, the role of gluten in overall health, and how celiac disease and gluten sensitivity are diagnosed and treated. It's equally essential that celiac disease patients recognize the increased risk of autoimmune thyroid disease and hypothyroidism.
Understanding celiac disease / what is celiac disease?
Celiac disease is also known as celiac sprue and gluten-sensitive enteropathy. (Outside the U.S., it's also frequently spelled coeliac disease.) When you have celiac disease, your body doesn't tolerate dietary gluten. Gluten is the term for specific proteins – primarily gliadin and glutenin –found in wheat, barley, rye, and some oats. Gluten is a popular food additive used in many processed foods.
In people with celiac disease, exposure to gluten inflames and damages the lining of your intestine. Eventually, celiac disease leads to villous atrophy, a wearing away of the villi that line the small intestine walls, creating permeability in the intestinal lining, allowing toxins and antigens to cross the lining and enter your bloodstream.
According to research, celiac disease affects about 1% of people in western countries, but that may underestimate the prevalence of celiac disease because many people have lifelong undiagnosed celiac disease, are misdiagnosed, or are only diagnosed later in life.
What are the signs and symptoms of celiac disease?
A variety of gastrointestinal symptoms are common in celiac disease. The following chart summarizes the common symptoms many patients with celiac disease experience:
Some people with celiac disease have no symptoms. Even when celiac disease is asymptomatic, when it goes untreated, it can lead to a variety of severe health complications, including:
- Infertility, miscarriage, and pre-term birth
- Low bone density (osteopenia and osteoporosis)
- Iron-deficiency anemia
- Neurological problems.
- Vitamin and mineral deficiencies
- Adenocarcinomas of the intestinal tract
Diagnosis and screening for celiac disease
Diagnosis of celiac disease is made by several methods. Most practitioners start with two antibody blood tests that can help confirm a celiac disease diagnosis. Elevated IgA anti-endomysial antibodies (EmA) and IgA anti-tissue transglutaminase (anti-tTG) antibodies are positive markers indicating gluten sensitivity. (An important note: You need to continue eating foods with gluten before the blood test because if you're already following a gluten-free diet, you may have a false negative test result.)
Doctors can also conduct genetic testing for human leukocyte antigens (HLA-DQ2 and HLA-DQ8). Elevated levels can also help diagnose celiac disease.
However, an endoscopic biopsy is the only truly conclusive way to diagnose celiac disease, which involves inserting an endoscope through the mouth down to the small intestine, where samples are taken to check for damage to the villi.
What about non-celiac gluten sensitivity?
Some people with celiac disease symptoms do not have the positive antibodies necessary to confirm a diagnosis. When those people resolve their symptoms after following a gluten-free diet, their condition is called non-celiac gluten sensitivity (NCGS), also known as gluten intolerance.
It's thought that NCGS is more common than celiac disease. Without a specific test, however, the diagnosis can only be confirmed by assessment of symptoms after a period of avoiding all gluten intake.
The symptoms of NCGS are the same as those of celiac disease.
Treating celiac disease and non-celiac gluten sensitivity
The only treatment for celiac disease is straightforward: you need to follow a life-long, strict gluten-free diet. That means avoiding ALL foods containing gluten – including wheat (including spelt, triticale, and kamut), rye, barley, and oats (unless labeled as gluten-free). In most celiac disease patients, patients start to see results – namely, a reduction of symptoms –within a few weeks. Over time, a gluten-free diet will usually resolve celiac disease symptoms, heal some or all of the intestinal damage that's already occurred, and help prevent any additional damage.
It's important to note that celiac patients must avoid consuming any gluten. Even a tiny amount of gluten can create inflammation and trigger celiac disease symptoms.
Some of the foods that typically include gluten include:
- Breads and baked goods
- Snack foods, like pretzels and crackers
- Beer and some other alcoholic beverages
- Some salad dressings and condiments
Gluten is also a common additive to many foods. Always carefully check food labels, and avoid foods containing gluten grains, malt, and brewer's yeast.
While a gluten-free diet requires a new way of eating, many foods can be included, including:
- Breads, baked goods, pasta, and cereals made from gluten-free grains and flours (including gluten-free oats, brown rice, buckwheat, millet, amaranth, almonds, potatoes, teff, sorghum, quinoa, millet, flax, arrowroot, taro, dasheen, peanut, and beans)
- Unprocessed meat, fish, poultry, and game
- Unprocessed fruits and vegetables
- Unprocessed beans
- Seeds and nuts
- Healthy fats like olive oil and avocados
- Dairy products
A gluten-free diet has several extra benefits. Some people will experience weight loss, have better control of blood sugar levels, and lower their hemoglobin A1C (HA1c) levels.
The treatment for NCGS is also to follow a gluten-free diet. Whether or not they need to be strictly gluten-free is up for discussion. Some NCGS patients have reported relief of symptoms with restriction – but not elimination – of gluten from the diet. Most experts, however, recommend that patients with NCGS either go entirely gluten-free or keep a careful food and symptoms diary and assess the type and volume of gluten eaten and any resulting symptoms. Over time, the goal is to identify what level of gluten intake is possible without triggering symptoms.
Some people with NCGS also find they have relief of symptoms by following a low-FODMAP diet. FODMAP stands for "fermentable oligosaccharides, disaccharides, monosaccharides, and polyols." FODMAPS are difficult-to-digest carbohydrates found in wheat and many other food products.
A low-FODMAP diet is more restrictive than a gluten-free diet in that, in addition to all foods that contain wheat, rye, and barley, it also eliminates specific high-FODMAP foods in other categories, summarized in the following chart:
Typically, a low-FODMAP is followed for a limited timeframe to help reduce symptoms and give the gut time to heal. Foods are then reintroduced slowly while carefully watching for recurrence of symptoms.
What is the connection between celiac disease and Hashimoto's disease?
Compared to the general population, you're at higher risk of a thyroid condition if you have celiac disease. At the same time, if you have an autoimmune disorder—especially autoimmune thyroid disease—you're at higher risk of having celiac disease.
In one study, more than 30% of celiac patients had elevated thyroid peroxidase antibodies – which is consistent with underlying Hashimoto's autoimmune thyroiditis. According to experts, some of the antibodies common in patients with celiac disease can bind to thyroid cells, which may be why celiac patients are at risk of thyroid conditions.
According to the Celiac Disease Foundation, an estimated 3.5% of patients with Hashimoto's have celiac disease. Other research has found that as many as 6% of people with hypothyroidism and autoimmune thyroid disorders have celiac disease. Experts believe that autoimmune thyroid patients face a higher risk of celiac disease. In people genetically susceptible to autoimmune disease, exposure to gluten essentially switches on an inflammatory response that allows the immune system to start attacking its glands, organs, or tissues. And because the protein structure of gluten is similar to thyroid tissue, one of the most common targets is the thyroid gland.
Researchers recommend that you receive screening if you fall into what they consider a high-risk category, which includes:
- those with conditions known to have a strong association with celiac disease, including autoimmune diseases like Hashimoto's thyroiditis and Graves' disease, hypothyroidism, and other endocrine diseases, like diabetes mellitus
- family members of celiac disease patients, because of the genetic predisposition to celiac disease
Treating celiac disease and Hashimoto's
Whether or not you have Hashimoto's or any thyroid disease, the treatment for celiac disease remains the same: following a gluten-free diet. Treatment for hypothyroidism requires a prescription thyroid hormone replacement drug, including:
- Levothyroxine (synthetic T4) drugs like Synthroid, Levoxyl, Unithroid, Euthyrox, Tirosint, and Tirosint-SOL
- Liothyronine (synthetic T3) drugs like Cytomel
- Natural desiccated thyroid (NDT) drugs like Armour, NP Thyroid, or compounded NDT
When hypothyroidism results from autoimmune Hashimoto's disease—the most common cause of an underactive thyroid in the U.S.—approaches to lowering the antibodies tend to be more customized.
They may include:
- Following a gluten-free diet
- Following an anti-inflammatory diet
- Following the specific Autoimmune Protocol (AIP) diet
- Taking selenium supplementation
- Low dose naltrexone
The good news is that there is clear evidence that a gluten-free diet may help your Hashimoto's and hypothyroidism. Researchers have found that following a strict gluten-free diet for a year can reduce thyroid antibodies and, in some cases, completely resolve subclinical hypothyroidism.
Should you eat gluten if you have Hashimoto's disease?
Even if you don't have celiac disease, with autoimmune hypothyroidism, you may have imbalances in your gut health—gut dysbiosis—or what's known as "leaky gut syndrome." These imbalances create inflammation that can increase your antibody levels and worsen your autoimmune symptoms. While gluten is a common culprit, some people have sensitivities to other common foods, including dairy products, soy, nuts, sugar, and processed foods. Eliminating gluten and other foods that create sensitivity for you may help relieve symptoms that aren't resolved by your thyroid medication or even resolve subclinical hypothyroidism in some cases.
How to get started? Consider an elimination diet to help identify your trigger foods and sensitivities. (If you don't know how to begin, consider a virtual consultation with one of Paloma Health's thyroid nutritionists.)
A note from Paloma Health
If you have celiac disease, experts recommend you be screened for thyroid disease. Similarly, you're considered at higher risk for celiac disease if you have an autoimmune disease. People with autoimmune conditions, including Hashimoto's thyroiditis and Graves' disease, should be screened, even without symptoms. Even if you aren't diagnosed with celiac disease, you may consider avoiding gluten to see whether it makes a difference for you and helps resolve lingering symptoms.
An important note: If you're a thyroid patient following a gluten-free diet, be aware that some thyroid hormone replacement drugs contain gluten. Your doctor and pharmacist can help you find a gluten-free thyroid drug that will work best for you.
Also, suppose you're a thyroid patient with unresolved symptoms, or you have celiac disease. In that case, periodic thyroid monitoring should be part of your ongoing thyroid care. Paloma Health makes this easy with the Complete Thyroid Blood Test kit, which includes the important Thyroid Peroxidase Antibodies (TPO) test that identifies Hashimoto's. You can get your thyroid easily and affordably tested right from home. Your at-home thyroid test kit contains everything you need for sample collection and sample analysis of TSH, free T3, free T4, and TPO antibodies, with the option to add a reverse T3 and vitamin D test.
After you receive your thyroid test kit by mail, you complete your sample with a painless finger prick and then send it back to the lab with pre-paid shipping. Your thyroid lab results are released to your secure online dashboard within days, similar to the wait time for in-person lab results, without travel, waiting, or inconvenience.
Paloma Health has an affordable and convenient solution when you need a diagnosis, treatment, or adjustments to your hypothyroidism care. Schedule a virtual visit with one of Paloma Health's top thyroid doctors for personalized care of your thyroid.