By Amy Burkhart MD, RD

Many people are told they have “mild celiac disease.”

“ What does that mean?”

Do they need a strictly gluten-free diet?

Can they “cheat” once in a while since it is only mild?

Are the long-term effects the same?

Does that mean they are really ” gluten-intolerant” and not celiac?”

What if they have “mild” non-celiac gluten sensitivity?

What then?

There is definite confusion around this topic.

First and most importantly, there is no such thing as mild celiac disease

This is a misnomer. Just as you can’t be “a little bit pregnant,”-you can’t have mild celiac disease. You either have celiac disease or you don’t.

The confusion arises because:

1. Interpreting the results of the biopsy and labs can be confusing.
2. Symptoms vary from patient to patient.
3. There is a  lack of education in the medical community about celiac disease.

The biopsy is currently the gold standard for diagnosing celiac disease

A biopsy is a procedure in which a small piece of tissue is taken and looked at under a microscope.  In combination with labs and history, it is used to verify the lab diagnosis of celiac disease. If the screening labs are positive or there is a  high suspicion of celiac disease due to family history and clinical history, the biopsy is done.

The biopsy is graded on what is called the “Marsh Classification System.”

• While this system’s details are beyond this article’s scope, it is important to know the grading system is based on a scale of 0-4.
• Zero is normal, and 1- 4 are abnormal. A person with celiac disease can have any number ranging from 1-4.
• Patients with a grade 1 or 2 may be told their celiac is “mild.”. The practioner is basing the “Mild” comment on the results of the grading system, but the amount of damage doesn’t determine if celiac is present, nor how “severe” of a case they have. They have it or they don’t.
• If the biopsy is abnormal and the labs and history fit, the person has celiac disease.
• It doesn’t matter if the grade is a 1,2,3, or 4  -they have celiac disease.
• The treatment is the same irrespective of the Marsh grade-a lifelong gluten-free diet. Not sometimes, not just on weekdays-always.

Many things affect the biopsy results.

Just as the symptoms of celiac differ from person to person, so do the biopsy results. Many things can affect the results of the biopsy. The person is doing the procedure, where samples are taken, and how many samples were taken-all affect the results. Besides, if the patient stopped eating gluten before the biopsy because they couldn’t tolerate feeling sick anymore, the results would be affected.

It often takes months to get an appointment for a biopsy, and patients don’t want to wait to stop gluten. It is making them sick. This may affect the results and make the damage look “mild.” Two months prior, it might have looked “severe.” The important point is it doesn’t matter. If the biopsy is positive for celiac disease, it is positive. The treatment is the same—a lifelong gluten-free diet.

Note: Please continue eating a gluten-containing diet until the biopsy is done so that the results are accurate. If you have trouble getting an appointment, ask to be placed on the cancellation list. Call often to check for any openings. If you are experiencing severe symptoms, explain that to them.

A study published in the Journal of Clinical Gastroenterology and Hepatology in March 2013 compared patients with lower-grade biopsies to those with more severe biopsies. Patients with mild celiac disease still had nutritional deficiencies in iron, B12, and folate, although these deficiencies were less severe than in those with more advanced disease. Additionally, while fewer patients with mild celiac had osteopenia and osteoporosis, these conditions were still present. Continuous exposure to gluten can worsen intestinal damage. Do you want to wait until it becomes severe or take action now to prevent it from worsening?

Celiac disease is being diagnosed earlier thanks to increased awareness among physicians and patients. More people are now being diagnosed with grade 1 or 2 changes. This progress is great news, but it’s important to remember that even these early stages are still celiac disease.

Every patient with celiac disease has different symptoms

No two people are alike. Does this mean someone has a “ mild” case of disease if their symptoms from exposure are less than someone else’s? No.

They all have celiac disease, and the treatment is the same. Regardless of symptoms, it is celiac disease, not gluten sensitivity. They are different conditions and the treatment is different.  We know some people have a clinically silent form of celiac disease. Externally they have no symptoms, but their biopsy shows damage. Do they need a strict gluten-free diet just like the person with overt symptoms? Absolutely.

They still have celiac disease.

No matter your symptoms or reaction to gluten, you still have celiac disease, and the treatment is the same

The severity of outward symptoms does not clearly match the internal damage caused by celiac disease. Many long-term risks of untreated celiac disease are well known. Even if you only experience mild symptoms like a headache or slight fatigue after eating gluten, your intestines are still being affected. The long-term risks are the same as for someone who is severely affected by cross-contamination.

You might have been tested for celiac disease because a sibling or parent was diagnosed, even if you had no symptoms. If your tests or biopsy were positive, you still have celiac disease. Whenever you eat gluten, your intestines are being harmed.

If your intestine is being affected, so is your future health.

1. There is no such thing as “Mild” celiac disease.
2. If the biopsy is read as positive for celiac disease-it is positive.  The grade doesn’t matter. The treatment is the same: a lifelong gluten-free diet.
3. The severity of external symptoms is not an indicator of how much gluten you can eat. If you have been diagnosed with celiac disease, the amount of gluten is safe. Mild external symptoms do not mean you are “gluten sensitive.” It is still celiac disease.
4. When possible, please seek out celiac specialists to get more comprehensive and accurate care