Coeliac disease: how to recognise it, how it is diagnosed, and how to live gluten-free in an Arab kitchen

What is coeliac disease, and could it explain your symptoms?

Coeliac disease, also spelled celiac disease, is an autoimmune condition. When someone with it eats gluten, a protein found in wheat, barley and rye, their immune system attacks the lining of the small intestine. Over time the tiny finger-like folds that absorb food, called villi, become flattened. Your gut then struggles to absorb iron, folate, calcium, vitamin D and other nutrients, even if you eat well. It is not a passing intolerance, because real damage happens inside the bowel whether or not you feel unwell after a meal.

It could explain your symptoms if you have ongoing bloating, diarrhoea or constipation, tiredness that never lifts, or anaemia that comes back every time you stop iron tablets. Surprisingly, many people with coeliac disease have no gut complaints at all, which is why it is missed so often. The only way to know is a blood test, usually tTG-IgA, done while you are still eating gluten, followed in most adults by a biopsy taken during an endoscopy.

The good news is that coeliac disease is very controllable. Once it is confirmed, a strict gluten-free diet lets the gut lining heal, and most people feel clearly better within weeks to months. No tablet replaces the diet, and there is no safe regular amount of gluten for someone with the condition, so the diagnosis needs to be certain before you change how the whole household eats.

How common is coeliac disease in Arab countries?

For decades coeliac disease was treated as a European illness, and that picture is out of date. A global meta-analysis published in 2018 in Clinical Gastroenterology and Hepatology pooled data on 275,818 people and found that about 1.4 percent had positive coeliac antibodies, while 0.7 percent had the disease confirmed by biopsy. It was more common in women than in men, and in children than in adults.

Arab data point the same way, with wide differences between countries. A 2020 systematic review by researchers at King Saud bin Abdulaziz University for Health Sciences in Riyadh gathered 35 studies covering 22,340 participants from 12 Arab countries. The highest rate in the general population, 3.2 percent, was reported in Saudi Arabia, and the lowest, 0.1 percent, in Tunisia. Children with type 1 diabetes had far higher rates, between 5.5 and 20 percent depending on the study.

Why does a region with bread at every meal miss so many cases? Partly because symptoms get blamed on something else: irritable bowel, worms and parasites, poor diet, or ordinary anaemia. Partly because testing is not routine in many clinics and follow-up is patchy. In a Riyadh study published in the Annals of Saudi Medicine in 2021, 11.5 percent of 539 teenagers and adults with type 1 diabetes screened positive, yet only 37 percent of those went on to have the endoscopy needed to confirm the diagnosis.

Symptoms beyond the stomach: anaemia, short height and weak bones

The textbook picture is chronic diarrhoea, a swollen belly and weight loss, but many adults have none of these. The Arab review above found that the most common presentation in children was failure to thrive and poor weight gain, followed by short stature, then abdominal pain, bloating and chronic diarrhoea. In adults the clue is often far from the digestive system.

The biggest clue is iron deficiency anaemia. A 2020 review in the journal Nutrients notes that iron deficiency anaemia is the only abnormal finding in about 40 percent of people with coeliac disease, because iron is absorbed in the first part of the small intestine, exactly where the damage is worst. If you have taken iron for months and your haemoglobin and ferritin barely move, and there are no heavy periods or blood loss to explain it, coeliac disease is one of the first things a doctor should check.

In children, a child who is drifting away from their growth curve, is clearly shorter than siblings and cousins, or starts puberty late deserves a coeliac blood test even if their tummy seems fine. In adults, untreated coeliac disease can be linked to early bone thinning, a fracture after a minor fall, repeated mouth ulcers, an itchy blistering rash on the elbows and knees called dermatitis herpetiformis, tingling in the hands and feet, raised liver enzymes, and difficulty getting pregnant.

The risk is higher in people with type 1 diabetes, autoimmune thyroid disease, Down syndrome or Turner syndrome, and in anyone whose parent, brother, sister or child has coeliac disease. A Saudi meta-analysis published in the Saudi Medical Journal in 2019 found that 15.6 percent of people in these higher-risk groups had positive coeliac antibodies. In large families, it is worth asking whether any relative has ever been told to avoid bread.

The tTG-IgA blood test: what it measures and how to read it

The first test looks for antibodies against an enzyme called tissue transglutaminase. On your report it usually appears as anti-tTG IgA, tTG-IgA or Tissue Transglutaminase IgA. When someone with coeliac disease eats gluten, their immune system makes these antibodies, and the level tends to rise with the amount of gut damage. The test is relatively cheap and widely available, and most private labs in the region either run it or send it to a reference lab.

Your result is compared with a cut-off printed on the report, often in U/mL. That cut-off differs between machines and labs, so read your number against your own lab's reference, not a figure from the internet. A result below the cut-off is reassuring if you were eating gluten and your total IgA is normal. A result above it means coeliac disease is likely and you need follow-up with a gastroenterologist. A very high result, many times the upper limit, makes the diagnosis more likely still.

A good lab also measures total IgA in the same sample. Some people naturally make very little IgA, which is more common in people with coeliac disease, and in them tTG-IgA can come back falsely normal. The doctor then uses IgG-based tests such as DGP-IgG or tTG-IgG. If your report shows tTG-IgA alone without total IgA, ask your doctor or the lab whether it was checked.

A positive blood test is not the end of the road. In adults the diagnosis is usually confirmed by an upper endoscopy, a thin camera passed through the mouth, during which several small samples are taken from the duodenum. In some children whose antibodies are very high and confirmed on a second blood sample, a paediatric gastroenterologist may make the diagnosis without a biopsy, following European paediatric guidance. That decision belongs to a specialist, not to a lab report on its own.

Why you must keep eating gluten until you are tested

This is the most common mistake. Someone reads about coeliac disease, cuts out bread for a few weeks, feels better, and then asks for a test. But antibodies fall and the gut lining starts to heal as soon as gluten is removed, so the blood test and the biopsy can come back normal even though the disease is there. You are then left with an unconfirmed label, not knowing whether you need to be strict for life.

The NHS states that you need to eat foods containing gluten for the tests to be accurate. Coeliac UK, the national charity, recommends eating at least 3 g and preferably 6 g of gluten every day for at least six weeks before testing, and continuing to eat gluten until your doctor makes a diagnosis. In kitchen terms, that means ordinary bread, pasta or other wheat foods at more than one meal a day.

If you have already gone gluten-free, do not restart bread today and test tomorrow. Talk to a doctor about a planned period of eating gluten again before the tests. If severe symptoms appear during that period, such as repeated vomiting or diarrhoea that leaves you dehydrated, stop and get medical advice rather than pushing through. Genetic testing for HLA-DQ2 and HLA-DQ8 can help here, because a negative result makes coeliac disease very unlikely, although a positive result does not prove it on its own.

Hidden gluten in Arab kitchen foods

Bread is the obvious source, whether it is Arabic flatbread, saj, tannour, Iraqi samoon or a French-style loaf. The harder part is the gluten you cannot see. Many traditional dishes are built on wheat in forms nobody calls bread. Freekeh is roasted green wheat. Bulgur, also called burghul, is cracked wheat, and it is the base of tabbouleh, kibbeh and many stuffings. Moroccan couscous and Palestinian maftoul are made from wheat semolina, and so are basbousa, maamoul and many semolina cakes.

Rice is naturally gluten-free, but rice cooked with toasted vermicelli, the everyday way of serving it in many homes across the Levant, Egypt and the Gulf, is not. Harees and jareesh in the Gulf are made from wheat, as are margoog and qursan. Levantine kishk is a mix of yoghurt and bulgur. Kunafa, qatayef, sambousek, fatayer and most bakery sweets contain wheat flour. Malt drinks, including the non-alcoholic malt beverages popular in the Gulf, are made from barley.

Then there are the truly hidden sources. Some spice blends, stock cubes and ready seasoning packets use wheat flour as a filler or anti-caking agent. Soy sauce is usually brewed with wheat. Shop-bought falafel may have flour added to hold it together, and is often fried in the same oil as breaded foods. Shawarma marinades, sauces thickened with flour, and meat dusted in flour before frying all count. If a label lists wheat, barley, malt, semolina, or simply starch without saying which kind, treat it with caution.

Gluten-free Arab staples you can rely on

The reassuring part is that a large share of the region's food is naturally gluten-free. Plain rice, potatoes, corn, lentils, chickpeas, fava beans, fresh meat, chicken and fish, eggs, milk, laban, labneh, white cheese, olives and olive oil, tahini, dates, nuts, vegetables and fruit are all gluten-free in their natural form. Hummus, ful medames, mujaddara made with rice, grilled meat without ready-made marinades, and most vegetable mezze can stay on the table.

Millet and sorghum, used for kisra and aseeda in Sudan and Yemen, are naturally gluten-free, as long as the flour has not been mixed with wheat or ground in the same mill. Rice flour and cornflour can replace wheat in muhallabia and as a coating for fried food. Oats are a special case: they contain no gluten themselves, but are often contaminated with wheat during processing, and a small number of people with coeliac disease react even to pure oats. Use only oats labelled gluten-free, and ask your doctor or a dietitian first.

A gluten-free diet does not have to mean expensive imported products. Gluten-free bread and pasta can be costly and hard to find outside big cities, and in some countries they may not be available at all. Building meals around rice, legumes, potatoes and fresh food is cheaper, closer to how our grandparents ate, and usually healthier than relying on processed substitutes, which can be high in sugar and fat and low in fibre.

Living gluten-free day to day: cross-contamination, restaurants and family meals

Even small amounts of gluten can keep the gut inflamed, so the details matter. Use a separate toaster or a clean pan, keep your own jar of jam or tahini so nobody dips a knife covered in breadcrumbs into it, and wash chopping boards and colanders well. Many families find it easiest to make shared dishes gluten-free, such as rice without vermicelli, and keep bread on the side for those who want it.

Restaurants are harder in the region, where staff may not know the word gluten. Explain it simply: no wheat, no flour, no bread, no bulgur, no semolina, and ask whether fried food shares oil with breaded items. Grilled meat with plain rice and a salad without croutons is usually the safest restaurant order. At Ramadan iftars and family gatherings, it helps to bring one dish you know is safe, and to explain to your hosts in advance that this is treatment, not fussiness.

Follow-up is part of treatment. Your doctor will usually repeat the tTG-IgA after several months to a year to check that it is falling, and check iron, ferritin, vitamin D, folate and sometimes bone density. If the antibodies stay high, the most common reason is hidden gluten, and seeing a dietitian is worth the effort. Do not start iron or vitamin supplements or stop any medicine on your own, because your doctor will decide what you need from your results.

When to see a doctor, and when it is urgent

See a doctor and ask for a coeliac blood test if you have anaemia that keeps returning, long-standing bloating or bowel changes, weight loss you cannot explain, a child who is not growing well, early bone thinning, or a first-degree relative with coeliac disease. Mention all your symptoms, including ones that seem unrelated to your stomach, and say clearly if you have recently cut down on bread.

Some symptoms should not wait for a routine appointment. Unexplained weight loss, blood in your stool, vomiting that will not stop, severe abdominal pain and signs of dehydration need prompt medical care. These can have many causes besides coeliac disease, and some of them are serious. Someone diagnosed years ago who suddenly gets worse despite a strict diet also needs a specialist review, because rare complications have to be ruled out.

Sources

• Singh P, Arora A, Strand TA et al: Global Prevalence of Celiac Disease: Systematic Review and Meta-analysis, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 2018
• El-Metwally A, Toivola P, AlAhmary K et al: The Epidemiology of Celiac Disease in the General Population and High-Risk Groups in Arab Countries: A Systematic Review, BioMed research international, 2020
• Safi MA: Celiac disease among at-risk individuals in Saudi Arabia, Saudi medical journal, 2019
• Aljulifi MZ, Mahzari M, Alkhalifa L et al: The prevalence of celiac disease in Saudi patients with type 1 diabetes mellitus, Annals of Saudi medicine, 2021
• Stefanelli G, Viscido A, Longo S et al: Persistent Iron Deficiency Anemia in Patients with Celiac Disease Despite a Gluten-Free Diet, Nutrients, 2020
• NHS: Coeliac disease, diagnosis
• Coeliac UK: Getting diagnosed