Around one person in a hundred carries coeliac disease, and most of them do not know it. Behind the rather technical name lies a very precise mechanism: gluten, the protein found in wheat, barley and rye, triggers an autoimmune reaction in these people that gradually destroys the villi of the small intestine. Not an intolerance, not an allergy: a proven autoimmunity, with a signature antibody, a biopsy that settles the question, and a single known treatment, a strict lifelong gluten-free diet. Chinese dietetics never named this disease, but it can read the terrain it leaves behind: an exhausted Spleen, Dampness thickening into Phlegm, an intestine that no longer sorts.
Coeliac disease: an autoimmunity, not an intolerance
The phrase “gluten intolerance” covers, in everyday language, three different biological realities that magazine headlines cheerfully blur together. Coeliac disease is not a sensitivity: it is an autoimmune condition in the strict sense, with an identified target.
The mechanism is now one of the best documented in all of autoimmunity. Gluten contains peptides (gliadin in particular) that our digestive enzymes cannot fully break down. In people carrying the HLA-DQ2 or HLA-DQ8 genes, present in roughly 30 % of the general population but in over 95 % of coeliacs, these peptides cross the intestinal barrier, are modified by an enzyme called tissue transglutaminase, and are then presented to the immune system as enemies. The immune system produces anti-transglutaminase antibodies (the well-known IgA anti-tTG) and anti-endomysial antibodies, and above all it attacks the wall of the small intestine: the villi, the tiny folds that multiply the absorption surface, gradually flatten. This is called villous atrophy.
The point worth holding onto is this: gluten is the trigger, but it is the patient’s own immune system that does the damage. Remove gluten and the attack stops; the villi regrow within months. Bring it back, even in traces, and the attack resumes silently, sometimes with no digestive symptom to announce it.
Diagnosis: serology then biopsy, in that order
The diagnostic pathway is codified and the order of the steps matters enormously. The first is a simple blood test: anti-transglutaminase IgA antibodies (together with a total IgA level, since IgA deficiency, common in coeliacs, skews the result). If the serology is positive, confirmation comes through an endoscopy with duodenal biopsies: the pathologist grades the villous atrophy on the Marsh classification.
The classic pitfall, and a frequent one, is starting the gluten-free diet before the work-up. Antibodies disappear within a few weeks of exclusion and the villi regrow, making the diagnosis impossible without going through a gluten challenge lasting several weeks, an unpleasant ordeal. Until the diagnosis is established, gluten stays on the plate, counter-intuitive though that feels.
Coeliac disease, NCGS, wheat allergy: the differential
Three conditions share the “gluten problem” label and call for different responses.
| Condition | Mechanism | Markers | Intestinal lesion | Treatment |
|---|---|---|---|---|
| Coeliac disease | Autoimmunity (HLA-DQ2/DQ8) | IgA anti-tTG, anti-endomysium | Villous atrophy (Marsh) | Strict gluten-free diet, lifelong |
| NCGS (non-coeliac gluten sensitivity) | Functional, mechanism debated | None (diagnosis of exclusion) | Absent | Reduction adapted to symptoms, no strict obligation |
| Wheat allergy | IgE-mediated allergy | Specific IgE, skin tests | Absent | Wheat exclusion, risk of acute reaction |
Distinguishing criteria between coeliac disease, non-coeliac gluten sensitivity and wheat allergy
NCGS is the diagnosis of exclusion: the symptoms (bloating, fatigue, brain fog) are genuinely real, coeliac serology and IgE are negative, and symptoms improve off gluten. The culprit may not even be gluten itself: the fructans in wheat, which are FODMAPs, reproduce the same picture in some patients, bringing NCGS closer to irritable bowel syndrome than to coeliac disease. The article on gluten and casein intolerances read through TCM covers this functional side in detail.
Wheat allergy is a different affair altogether: a rapid IgE-mediated reaction (hives, swelling, sometimes shock), mostly affecting children and often fading with age. It does not attack the villi.
Gluten-free living: avoiding the pitfalls of the diet
The strict gluten-free diet is the only treatment for coeliac disease, and it works: the villi regrow, the antibodies normalise, the complication risk falls away. But “gluten-free” does not mean “problem-free”. A badly constructed diet has pitfalls of its own.
The deficiencies to watch. Industrial gluten-free products are often poor in fibre, iron, folate and B vitamins, because the substitute flours (maize, white rice, starches) are not fortified the way wheat flour is. In the early months, the deficiencies accumulated during the years of malabsorption also need repairing: iron, calcium, vitamin D, zinc, B12. A baseline work-up followed by annual monitoring of serology and deficiencies is part of the treatment.
The genuine substitute grains. Rice, buckwheat, quinoa, millet, sorghum, teff, maize: the family of gluten-free grains and pseudo-grains is broad, provided you choose the whole versions rather than refined starches. Oats raise a separate question: they contain no gluten but a related protein, avenin, tolerated by most coeliacs; the problem is cross-contamination with wheat in the supply chain. Only certified gluten-free oats are suitable, introduced cautiously.
Traces matter. For a coeliac, cross-contamination is not purism: breadcrumbs on a shared worktop, a shared deep-fryer, a jar of spread where the knife has dipped in are enough to restart the attack. “Gluten-free” means under 20 parts per million, which is everyday vigilance, not a gesture of principle.
The TCM reading: Dampness-Phlegm and a Spleen terrain
Chinese dietetics obviously never spoke of antibodies or HLA. But the picture it reads in untreated coeliac disease is remarkably precise: a Centre that no longer transforms what it receives.
In organ language, the Spleen is responsible for transportation and transformation: sorting the food essences, sending the clear upwards, sending the turbid downwards. Coeliac disease is precisely a failure of that sorting: the small intestine, seat of the separation of pure from impure in Chinese physiology (this is the function of the Small Intestine, which depends on Spleen Qi), lets through what it should block and no longer absorbs what it should send up. The result forms the classic pairing of Spleen deficiency with Dampness: loose or unformed stools, bloating, post-prandial fatigue, a puffy tongue with a white coating.
When Dampness persists, it thickens. This is the move into the territory of Phlegm (痰, Tán): the tongue becomes greasy, the body retains water or fat without eating more, “phlegmy” signs appear elsewhere (loaded sinuses, discharges, swollen nodes). The paradoxical malnutrition of coeliac disease, where the patient can be simultaneously overweight and deficient, writes itself perfectly in this model: a fullness of Dampness coexisting with an emptiness of Qi.
Rebuilding the Centre: what Chinese dietetics adds to gluten-free
Gluten exclusion is non-negotiable, but it only removes the trigger. The terrain still needs repairing, and that is where Chinese dietetics brings something the Western gluten-free diet does not formulate: a logic of digestive rebuilding.
Cooking to ease the sorting. In an intestine whose villi are regrowing, anything arriving raw, cold or highly fermentable costs a great deal to transform. The early months favour the cooked and the warm: long-cooked rice or millet congee, vegetable soups, gentle stews, poached fruit. Rice congee (粥, zhōu), the convalescence food par excellence in China, is exactly suited to a healing intestine: it nourishes Spleen Qi without demanding any sorting work.
Choosing grains that tonify. Millet and brown rice (Neutral to slightly Warm, Spleen-Stomach tropism) replace wheat ideally: millet was in any case the Spleen’s own grain in the dietetic texts. Buckwheat, slightly cool, suits when Dampness turns hot. White starches (tapioca, glutinous rice, refined flours) fill but tonify nothing: they are the “empty calories” of the industrial gluten-free diet.
Draining residual Dampness. Once digestive calm returns, the foods that help the Spleen resorb Dampness take their place: Job’s tears (薏苡仁, yì yǐ rén), adzuki beans, bitter orange and citrus zest as seasoning, umbelliferous vegetables (fennel, celery). The eight-week gut repair protocol gives the full sequence, which applies almost as-is to the post-diagnosis phase.
Sparing the Centre’s morale. The Spleen dislikes excessive rumination as much as excessive sugar. A coeliac diagnosis often arrives with a real mental load (fear of traces, grieving spontaneous eating) that tires the Spleen at the very moment it needs to be spared. Meals taken calmly, without screens or agitation, are not a behavioural detail: they are Centre dietetics.
Frequently asked questions about coeliac disease
Can you become coeliac as an adult?
Yes, and this is now the most common presentation. The disease can declare itself at any age, including after 60, often after a trigger: intestinal infection, pregnancy, surgery, major stress. The gene has been there since birth, but expression of the disease sometimes waits for decades.
Does a negative serology rule out coeliac disease?
Not entirely. IgA deficiency (commoner in coeliacs) produces falsely negative anti-tTG IgA; an already low-gluten diet lowers the antibodies; and there are rare “seronegative” coeliacs where only the biopsy speaks. If clinical suspicion is strong, the work-up continues despite a negative serology.
Is a gluten-free diet good for everyone?
No. Without a coeliac indication, documented NCGS or allergy, the gluten-free diet has shown no proven benefit, and it carries costs: less fibre, more sugars and additives in substitute products, a risk of folate and iron deficiency, and social isolation around meals. Without a diagnosis, working on the quality of the plate beats excluding wheat.
How long before the intestine heals?
The mucosa regrows quickly, but full restoration of the villi generally takes 6 to 24 months in adults, sometimes longer in older patients or those diagnosed late. Antibodies normalise faster, often within 6 to 12 months of strict exclusion. Symptoms persisting beyond a year of rigorous dieting call for a search for hidden gluten or refractory coeliac disease, which is rare.
Healing the mucosa, repairing the terrain
Coeliac disease is one of the very few autoimmune conditions whose exact trigger is known, and whose treatment sits on the plate. A strict gluten-free diet puts out the attack; it does not by itself rebuild the terrain that years of malabsorption have left. Chinese dietetics takes over precisely at that point: recooking the Centre, tonifying the Spleen, draining Dampness and supporting weakened Immunity, until intestinal sorting has recovered its sharpness.
In the Yin Shi app, the food sheets give each substitute grain its thermal nature and its tropism: millet and brown rice tick the boxes of Spleen deficiency, and Chinese yam those of the healing intestine.
Further reading: gluten and casein intolerances in TCM, leaky gut and zonulin, the microbiome as Spleen Dampness, the concept of Spleen deficiency, and the gut repair protocol.
To go further
Yin Shi ecosystem resources directly related to this article.