Food and the gut
Gluten sensitivity in India: coeliac disease, wheat intolerance and diagnosis
Coeliac disease is an autoimmune condition in which gluten, a protein in wheat, barley and rye, damages the lining of the small intestine. A community study in northern India found it in about 1 in 100 people, and most were undiagnosed. It often shows as anaemia, tiredness or poor growth without any bowel symptoms. Diagnosis needs a blood test and an endoscopy, done while still eating gluten. Treatment is a strict gluten-free diet.
In short
- Coeliac disease is not rare in India, particularly in the wheat-eating north.
- Many patients have no diarrhoea. Iron-deficiency anaemia that does not respond to iron is a common clue.
- Do not start a gluten-free diet before testing.
- With a strict diet the intestine heals, and the complications are prevented.
For the full guide to the tests and the gluten-free diet, see coeliac disease.
What happens in coeliac disease?
In people who carry certain genes, gluten triggers the immune system to attack the lining of the small intestine. The tiny projections that absorb nutrients become flattened. Iron, folate, calcium, vitamin D and other nutrients are then poorly absorbed.
What are the symptoms?
Bowel symptoms
- Long-standing loose stools
- Bloating and gas
- Abdominal discomfort
- Weight loss
- In children: poor growth, a swollen abdomen, irritability
Symptoms outside the gut
- Iron-deficiency anaemia that does not improve with iron tablets
- Tiredness
- Short stature or delayed puberty
- Weak bones or fractures at a young age
- Mouth ulcers
- Abnormal liver enzymes with no other explanation
- Difficulty conceiving, or repeated miscarriage
- An itchy, blistering rash on the elbows, knees or buttocks
Some people have no symptoms and are found through family screening.
Who should be tested?
- Anyone with the symptoms above
- People with IBS-type symptoms and loose stools
- Parents, brothers, sisters and children of a person with coeliac disease
- People with type 1 diabetes or autoimmune thyroid disease
- People with unexplained anaemia, osteoporosis or raised liver enzymes
How is it diagnosed?
Blood test
An antibody test (tissue transglutaminase IgA), along with a total IgA level. You must be eating gluten daily for the test to be reliable.
Endoscopy with biopsy
In adults, a positive blood test is confirmed with an upper GI endoscopy. Small samples from the duodenum show the damage under the microscope.
Genetic test, in selected cases
The absence of the coeliac genes rules the condition out. It is useful when someone has already stopped gluten and the other tests cannot be interpreted.
How is it treated?
The treatment is a strict gluten-free diet for life.
- Avoid: wheat in every form (atta, maida, sooji, dalia), barley and rye, and processed foods that contain them
- Eat freely: rice, millets, maize, pulses, besan, vegetables, fruit, dairy, eggs, fish, meat, nuts
- Watch for contamination: flour ground in a mill that also grinds wheat, shared frying oil, and shared utensils
- Correct deficiencies: iron, folate, vitamin B12, vitamin D and calcium, guided by tests
- Follow up: a repeat antibody test and review after six to twelve months, and a bone density scan where indicated
A dietitian’s guidance at the start makes the difference between partial and full recovery. Symptoms usually improve within weeks. The lining takes months to two years to heal.
What if I react to wheat but do not have coeliac disease?
Four different problems are grouped under “gluten sensitivity”. They are diagnosed and treated differently.
| Problem | What it is | Typical picture | How it is diagnosed | Diet |
|---|---|---|---|---|
| Coeliac disease | An immune reaction to gluten that damages the small intestine | Loose stools, anaemia, tiredness, thin bones; sometimes no symptoms | Antibody blood test and biopsy, while eating wheat | Strict gluten-free diet for life |
| Wheat allergy | An allergic reaction to wheat proteins | Hives, swelling or wheezing soon after eating wheat | The history, skin prick or blood allergy tests, and a supervised food challenge where needed | Avoid wheat |
| Non-coeliac wheat sensitivity | Symptoms from wheat with coeliac disease and allergy ruled out | Bloating, pain and tiredness after wheat | No blood test exists. Symptoms settle when wheat is removed and return when it is tested again | Reduce wheat; the same strictness is not needed |
| Fructan intolerance in IBS | Fermentation of fructans, a carbohydrate in wheat, onion and garlic | Gas and bloating, also after onion and garlic | A structured low-FODMAP trial with reintroduction | Smaller portions of wheat are usually tolerated |
In a blinded trial of 59 people who believed they were sensitive to gluten, bars containing fructan caused more symptoms than bars containing gluten, and gluten caused no more than a dummy bar.
Non-coeliac wheat sensitivity does not damage the intestine. See gluten and gut health and food intolerance blood tests.
Why does a correct diagnosis matter?
Untreated coeliac disease leads to anaemia, weak bones, poor growth in children, fertility problems and, rarely, a lymphoma of the intestine. These are prevented by the diet. A firm diagnosis also tells the family who else should be tested.
When should I see a doctor?
See a doctor for diarrhoea lasting more than four weeks, unexplained anaemia, weight loss, or a child who is not growing as expected. Ask for coeliac testing before changing the diet.
Questions patients ask me
Is coeliac disease the same as wheat allergy?
No. Coeliac disease is an autoimmune condition that damages the intestine slowly. Wheat allergy is an immediate allergic reaction. They are diagnosed by different tests.
Can coeliac disease develop in adulthood?
Yes. It can appear at any age, including in people who have eaten wheat for decades without trouble.
Can I eat a little wheat occasionally?
No. In coeliac disease even small amounts keep the damage going, with or without symptoms.
Do my family members need testing?
Yes. Parents, brothers, sisters and children have a higher risk and should have the blood test, even if they feel well.
Sources
This page is written for patients and is based on the guidelines and studies below. It is for education and does not replace a consultation.
- American College of Gastroenterology guideline on coeliac disease. Rubio-Tapia A et al. Am J Gastroenterol. 2023. PubMed 36602836
- Community study of coeliac disease prevalence in northern India. Makharia GK et al. J Gastroenterol Hepatol. 2011. PubMed 21182543
- Salerno experts’ criteria for non-coeliac gluten sensitivity. Catassi C et al. Nutrients. 2015. PubMed 26096570
- European Academy of Allergy and Clinical Immunology guideline on the diagnosis of food allergy. Santos AF et al. Allergy. 2023. PubMed 37815205
- Blinded crossover trial of gluten and fructan in people with self-reported gluten sensitivity. Skodje GI et al. Gastroenterology. 2018. doi:10.1053/j.gastro.2017.10.040
- American College of Gastroenterology guideline on irritable bowel syndrome. Lacy BE et al. Am J Gastroenterol. 2021. doi:10.14309/ajg.0000000000001036