Saturday, June 12, 2010

Celiac Disease and Wheat Intolerance

 Wheat Intolerance
·         Common: Celiac Disease appears to be at least 1% of the population.  A significantly larger percentage of the population has non-celiac related wheat intolerance
·         Slowly diagnosed – Celiac disease typically takes four years to reach a diagnosis if you’re symptomatic leaving 90% with CD unaware, undiagnosed or misdiagnosed.
·         Serious - untreated wheat intolerance can be very serious.  A study of military recruits 50 years ago has found that intolerance of wheat gluten is four times more common today than it was in the 1950’s.
What Causes Celiac Disease?
Celiac disease is an immune mediated disease triggered by exposure to Gluten (name from the Greek word for “Glue” and found in wheat, barley, rye).  Gluten contains Gliadin and one mechanism for the Celiac Disease related immune damage occurs when Gliadin is modified by enzymes in our intestines (such as tissue transglutaminase).  The resulting proteins cause an immune-mediated toxic reaction that causes damage both to the GI tract small intestine as well as other areas of the body. Untreated, the small intestine becomes increasingly damaged and less able to absorb nutrients.
Why the Increase in Celiac Disease?
1.      We have cultivated our wheat crops to have higher levels of gluten.  More gluten means more stickiness and generally this makes for better taste and texture.
2.      Our diet consists of high intake of gluten rich wheat products.
3.      Yeast overgrowth in our colon.  Most commonly candida overgrowth is related to our use of antibiotics, birth control pills and prednisone like medications.  Candida contains amino acid sequences that are identical to or very similar to those found in the celiac induced immune response. Candida overgrowth in our intestines can trigger the production of antibodies that not only attack candida but also react to gluten (wheat, barley and rye). When we eat gluten containing foods, we then experience an inflammatory response characteristic of celiac disease.
4.      Eating whole grain and sprouted grains actually increases gluten intake as they have higher amounts.
5.      Autoimmune diseases in general are increasing and several of these are associated with Celiac disease.  What causes autoimmunity? High intake of animal products and yeast overgrowth are just 2 factors associated with a higher risk of autoimmunity.  Type 1 Diabetes appears genetically linked with the genes that increase the risk for Celiac disease.  5-10% of those with Diabetes Type will also develop Celiac disease.
It is not just in the genes and it is not just Celiac disease that is the issue. Gluten and other grains rich in lectins capable of directly damaging to the majority of tissues in your body without requiring a specific set of genetic susceptibilities.

Not Just in the GI tract
Unfortunately, the offending glycoproteins in Gluten are extremely small and resistant to breakdown by living systems.  These proteins tend to accumulate and become incorporated into tissues where they interfere with normal biological processes such as:
-          Causing the production of inflammatory chemical messengers which can cause inflammation throughout the body
-          thymus atrophy
-          crosses the blood-brain barrier and causing brain injury
-          interfere with gene expression
-          disrupt endocrine function
Symptoms of Gluten-Intolerance
Symptoms of the disease are often gastrointestinal (many with Celiac Disease have been diagnosed with IBS – Irritable Bowel Syndrome).  Not everyone has Gut symptoms when they have Celiac Disease.  Consider testing if you have one of the following issues, conditions on an ongoing basis:
·         Bloating
·         Gas
·         Diarrhea
·         Abdominal pain
·         Nausea/vomiting
·         Foul smelling stools
·         Gastroesophageal reflux disease
·         Inflammatory Bowel Disease
·         Irritable Bowel Disease

Some with Celiac Disease actually lack the gastrointestinal symptoms.  Aside from the gastrointestinal symptoms, celiac disease can cause numerous problems:

·         Weight loss
·         Fatigue
·         Joint pain
·         Depression
·         Hypoglycemia - low blood sugar
·         Irritability and behavioral changes
·         Bone loss: Osteopenia or Osteoporosis
·         Muscle cramps
·         Hair loss
·         Canker sores inside the mouth
·         Tooth discoloration or loss of enamel
·         Seizures
·         Cerebellar ataxia
·         Peripheral neuropathy
·         Any Autoimmune disease: i.e. Rheumatoid arthritis, Systemic Lupus
·         Psoriasis
·         Thyroid disease
·         Short stature, unexplained
·         Delayed puberty
·         Dementia
·         ADD
·         Anemia (iron deficiency that does not respond to iron)
·         Microscopic Colitis
·         Miscarriage
·         Infertility
·         Failure to thrive in infants
·         Growth retardation in children
·         Premature menopause
·         Dermatitis Herpetiformis – a skin condition with itching and blistering
·         Asperger’s/Autism
·         Schizophrenia
·         Vitamin deficiencies (especially vitamin K which can cause bleeding problems)
·         Intestinal Lymphomas
·         Pancreatic insufficiency
·         Dermatitis Herpetiformis (DH) - a skin manifestation of celiac disease characterized by blistering, intensely itchy skin. The rash has a symmetrical distribution and is most frequently found on the face, elbows, knees and buttocks. DH patients can have intestinal damage without obvious GI symptoms. (DH) is diagnosed by a biopsy of a skin lesion and staining for IgA in the tissues. More than 85% of DH patients have small bowel sensitivity to gluten. Everyone with DH needs to follow a gluten-free diet.
The symptoms of Celiac Disease can begin at any age. The disease can be triggered for the first time after stressors such as infections, emotional stress, childbirth or surgery.

 Diagnosis

Specific antibody blood tests help identify the presence of Celiac Disease and are the initial step in screening includes the following tests (note: usually one must be eating gluten containing foods when these tests are done in order for them to be accurate):
  • Tissue transglutaminase antibody (tTG - IgA/IgG) (blood or stool)
  • Anti-gliadin antibody (AGA-IgG, AGA-IgA) (blood or stool)
  • Stool studies for tTG (Enterolab)
  • Genetic testing (cheek swab, stool sample or serum)
  • Total serum IgA (blood)
  • Response to a Gluten free diet
Most would say the most cost effective screening test is to test the blood for Anti-Tissue Transglutaminase (tTG-IgA).  All labs are less than 100% in their ability to identify disease this test can be falsely negative, particularly with early disease.  Some advocate always checking for the anti-gliadin antibodies.  Dr. Kenneth Fine, M.D. (a gastroenterologist who started and owns Enterolab in Dallas) feels the best way to diagnose early Celiac Disease is using stool tests (you can read his article HERE).  You can order directly from Enterolab without a physicians order. His experience has been that unlike blood tests, even those avoiding gluten can still test positive.  Enterolab is reasonably priced and may be more sensitive than serum testing at detecting antibodies associated with Celiac disease as well as wheat sensitivity. The panels of tests cost less than adding individual tests.  If you suspect you or a loved one have a problem with wheat you may wish to order of the Enterolab stool studies, for example:
Gluten Sensitivity Stool Panel Complete ($249) Combination of stool test for gluten sensitivity, stool test for tissue transglutaminase, and test for intestinal malabsorption. These tests complement one another and are best ordered together.
Gluten Sensitivity Stool and Gene Panel Complete ($369) This would be a very thorough test which includes gluten sensitivity stool test, tissue transglutaminase stool test (test for the autoimmune reaction caused by gluten sensitivity), intestinal malabsorption test, gluten sensitivity gene test (HLA DQ2/DQ8 genes) and a milk sensitivity stool test.
Labcorp has several useful blood tests:
Tissue Transglutaminase (tTG), IgA  Test Number: 164640 CPT Code: 83516 (this would be the lowest cost screen)
Celiac Disease Antibody Screen   This is more comprehensive than the above test. This includes tests for: Deamidated Gliadin Antibodies (DGP), Gliadin and Tissue Transglutaminase (tTG) Antibodies.  Labcorp Test Number: 334971 CPT Code: 82784; 83516(x2) (costs more but tests for more)
Celiac Disease HLA DQ Association   A genetic test for HLA Typing, DQ2, DQ8      Test Number: 167082 CPT Code: 83891; 83894(x2); 83896(x44); 83898(x2); 83912  (This test can be positive even before one develops the condition)


Dr. Scot Lewey is another Gastroenterologist with a focus on Celiac Disease.  He points out that when genetic testing is done, it is most sensitive when it contains the alpha and beta subunits. Laboratories in the U.S. that are known to offer complete alpha and beta subunit genetic testing include Kimball Genetics and LabCorp.  Quest and Enterolab only test for the beta subunit portions and therefore their test can miss part of a minor alpha subunit that carries a risk of Celiac disease. A negative DQ2 and DQ8 report from these labs may not necessarily be truly negative for the risk of Celiac disease.
Non-Celiac Gluten Sensitivity
Many people have gluten sensitivity with both GI and systemic symptoms that do not actually have Celiac Disease.  Non-Celiac Gluten Sensitivity should be suspected if you have positive
-          Antigliadin antibody (AGA IgA and IgG)
-          Stool tests at Enterolab
-          A positive response to an elimination diet (remember history is always a key to diagnosis)
Most with positive antibody tests have endoscopy to both assess the amount of damage to the intestinal lining called villi as well as to perform a biopsy.  I question whether the risk of this procedure is justified (not to mention the expense).
A follow-up biopsy or blood work may be ordered several months after the diagnosis and treatment. Normalizing lab results indicate that you have responded to treatment, thereby confirming the diagnosis. However, this does not suggest that the disease has been cured.  The diet is lifelong (see below).
Treatment
1.      Follow a lifelong Gluten-free diet (by far the most important)
The treatment for celiac disease or gluten intolerance is a gluten-free diet, which means abstaining from grains and any food that contains gluten. All forms of wheat (including semolina, spelt, kamut, einkorn, durum and faro) and related grains rye, barley and triticale must be completely eliminated. 
Typically, avoiding gluten for a week or two is enough to see significant improvement.
2.      Cleanse and Restore the GI tract
Since the immune system is thrown off balance by yeast overgrowth, it would also be wise to do a Candida Cleanse (see March 2010 blog post on the topic of Yeast)
Probiotics have been shown to decrease inflammation in Celiac disease.  Dr. Mercola has a good article on this HERE
3.      Eat Plant Based
An immune system friendly Plant Based Diet will reduce inflammation
4.      Restore nutritional Deficiencies
Strontium and Vitamin K2 are important for strong bone (see the NaturalWellnessChoices.com Oct 2009 blog post on Strontium).  Often women will want to supplement Progesterone and DHEA to promote bone health and men will often need supplemental testosterone. 
5.      Look for and treat commonly associated diseases such as thyroid Disease
Thyroid problems are more common in those with Celiac Disease.  For more information, please read my blog post on the topic of the Candida, Celiac, Thyroid Connection.
To help break down hidden sources of gluten there are products such as Gluten Defense by Enzymatic Therapy that contain enzymes that help break down gluten and casein (dipeptidyl peptidase also known as DPP IV).

Hidden Sources of Gluten

Gluten may still be hiding in processed foods like ready-made soups, soy sauce, candies, cold cuts, and various low- and no-fat products, just to name a few, under labels such as:
·         Malts
·         Starches
·         Hydrolyzed vegetable protein (HVP)
·         Texturized vegetable protein (TVP)
·         Natural flavoring
Celiac.com – list of Gluten containing foods.  See The Gluten Solution site. They also offer more detailed information about the current state of gluten-free labeling legislation.
The healthiest way for anyone to eat is to enjoy a diet of fresh, whole foods (preferably organic whenever possible). Those will Celiac Disease would be wise do eat less processed foods that are more likely to have hidden gluten sources.
However, this is truly only one problem linked to eating wheat, and may not even be the most serious one. That honor may actually go to wheat lectin.
Beyond Celiac Disease: Why We all should limit Lectin Rich Grains
Lectin is a defense mechanism for the wheat plant, designed to ward of its natural enemies such as fungi and insects. Unfortunately, this protein is also very resistant to breakdown by living systems, and it easily accumulates in tissues where it interferes with normal biological processes and acts as an anti-nutrient.  Typically, sprouting, fermenting or digestion can help to negate some of the harmful effects of such anti-nutrients (as in the case of fermenting soy, which removes many of its anti-nutrient properties). However, lectins are resistant to these types of processes.
The Dangers of Wheat Lectin
What is lectin’s potential to disrupt your health, exactly? Here is a sampling of its dangers, which you can read about more in-depth here:
·         Pro-Inflammatory: lectin stimulates the synthesis of pro-inflammatory chemical messengers, even at very small concentrations.
·         Immunotoxic: lectin may bind to and activate white blood cells.
·         Neurotoxic: lectin can pass through your blood-brain barrier and may attach to the protective coating on your nerves known as the myelin sheath. It is also capable of inhibiting nerve growth factor, which is important for the growth, maintenance, and survival of certain target neurons.
·         Cytotoxic (Toxic to cells): lectin may induce programmed cell death.
Further, research shows lectin from wheat may even:
·         Interfere with gene expression
·         Disrupt endocrine function
·         Adversely affect gastrointestinal function
·         Share similarities with certain viruses
The Gluten lectin called WGA Lectin is capable of passing through cell membranes of your intestines, gaining entry into your body.  
Lectin is most likely to cause problems with the intake if high and the gastrointestinal barrier has been compromised such as with yeast overgrowth or use of non-steroidal medications like Ibuprofen.   Grains such as rice, wheat, spelt, rye, etc. have high levels of lectin. 
Many of us will benefit from the elimination of grains – especially wheat.  If you eliminate grains from your diet strictly for 2 weeks and improve it is likely you are experiencing health problems related to them.  If your symptoms then return upon reintroducing the grain you would want to avoid it.

For more information