Recent programs to screen high-risk groups have identified a growing group of patients with celiac disease and no symptoms. Some of these individuals underwent screening because of relatives with celiac disease, while others were screened because they have a disease, such as diabetes, which is associated with celiac disease.

Convincing a patient with no symptoms that following a very restrictive diet is in their best interest is a major challenge for health care providers. I have spent many hours in the office debating this issue with some very smart teenagers and have honed my arguments over the years:

1. First of all, many patients who deny symptoms simply are not aware of them. After starting a gluten-free diet, many patients are surprised that their stomachaches, which they had interpreted as a normal occurrence, resolve completely. Others find new energy on the diet after steadfastly denying ever having felt excessively fatigued. This inability to recognize symptoms is even more of a problem for children with celiac disease, who may never have had the experience of feeling "well."

   So, argument No. 1 is that an individual with celiac disease may just feel better on a gluten-free diet.

2. Secondly, poor absorption of nutrients may gradually lead to medical problems not always recognized in their early stages. For instance, poor absorption of iron may lead to iron deficiency and eventually to anemia. Usually, the red blood cell count drops very slowly and the onset of the associated weakness is very slow. Loss of bone density resulting from calcium malabsorption may be totally silent until a fracture occurs. Although anemia is rather easily treated with a gluten-free diet and iron supplementation, osteoporosis is very difficult to reverse, even with diet, calcium and vitamin D supplementation, and medications.

   So, argument No. 2 is that malabsorption may lead to dietary deficiencies that will eventually impact the health of the patient with untreated celiac disease.

3. Third, other autoimmune diseases are more apt to occur in patients with untreated celiac disease. Autoimmune diseases are the result of the immune system inappropriately attacking organs of the body. Examples of autoimmune diseases other than celiac disease are diabetes, autoimmune thyroid disease, and some kinds of arthritis. Although the evidence is somewhat controversial, most celiac disease experts feel that the longer a patient with celiac disease is exposed to gluten, the greater chance he or she has of developing another autoimmune disease. How this exactly occurs is unknown, but there is speculation that damage to the small intestine due to celiac disease permits toxic substances to penetrate and trigger the immune system in various organs.

   So, argument No. 3 is that strict compliance with a gluten-free diet may decrease the chance of developing serious autoimmune diseases.

4. The final argument is the most frightening. Patients with untreated celiac disease have a greater risk of developing certain kinds of cancer, including tumors of the small intestine and esophagus. This risk is still very low, although many fold higher than in patients without celiac disease. The good news is that there is some evidence that this increased risk is reversed with strict adherence to a gluten free diet, although more research in this area is required.

   So, argument No. 4 is that strict compliance with a gluten-free diet may decrease the risk of developing cancer.

Whether to screen all high risk patients without symptoms of celiac disease remains controversial in the medical community. However, I hope I have convinced you that once diagnosed, celiac disease should always be treated.