December 5, 2016

Gluten - It is time.

Part II

Tolerance to food proteins is a key part of the gluten story and failure at this point is the key to Celiac disease, Crohn's disease and many other disorders. I believe that the failure of my system to tolerate gluten precipitated a worsening of my coronary artery risk profile.

Statistics show us that people that have true celiac disease carry double the risk of coronary artery disease and 1.4 times the risk of stroke. We do not have similar statistics for humans who do not have celiac disease but still react to gluten.

My celiac markers are negative, however, removing gluten ushered in a shift in my cholesterol risk parameters. Was it the gluten removal or the complete reduction of all types of flour and sugar in my diet or a combination of both that played the greatest role? To find the answer, let us start at the beginning.

What is gluten?

Gluten is a family of proteins that are found in wheat, rye, barley as well as some other wheat cousins like farro and kamut. Gluten is prized for its elastic ability when producing bread, pizza and other wheat flour based foods. Anyone who has ever tried a gluten free pizza will immediately understand what the lack of gluten does to the pizza's shape and mouth feel, not good.

There are three distinct clinical disease entities related to gluten: wheat allergy, celiac disease and non celiac gluten sensitivity.

Celiac disease is the most severe reaction to gluten that affects 1-2% of Americans. It is a complete failure of immune tolerance to the gluten proteins that causes severe inflammation of the small intestine leading to atrophy of the intestinal lining. The disease primarily presents with failure to thrive, abdominal pain and bloating, and a myriad of extra intestinal symptoms including brain irritation, rash, pregnancy miscarriage and cancer. See this link for more details.

Wheat allergy is rare occurring in less than 0.5% of Americans. It is an immediate IgE mediated immune reaction to wheat proteins causing classic food allergy symptoms: mouth swelling, difficulty breathing, hives and potentially acute death.

Non celiac gluten sensitivity or NCGS is more common affecting up to 20% of Americans. It is a slow immune mediated reaction to gluten that primarily causes brain fog, irritable bowel syndrome, joint pain, rash, fatigue, anxiety/depressive symptoms and headaches. The pioneering work by Dr. Alessio Fasano explains this disorder in detail. Unlike the other two disorders, NCGS does not have a consistent classical biomarker like the antibody TTG for celiac disease causing many physicians to doubt its relevance and existence.

One key difference between Celiac disease and NCGS is that the Celiac population develops autoimmune and cancer associated diseases like Hodgkins lymphoma at a higher frequency.

Understanding these differences is critical to making an educated decision regarding your health. Having any of the above symptoms that are not the allergy anaphylaxis type should push one to attempt a 30 day trial off of gluten containing foods and then a rechallenge to assess causality of symptoms.

As I stated, the medical community continues to have a hard time believing in a disease until they have a test. A black swan indeed. Witness the years that Celiac patients were told that they were crazy until the antibodies TTG and anti-gliadin were found. Viola, now they are diseased!

To answer this conundrum, a group out of Bologna, Italy looked at the truth behind NCGS symptoms. The study published in Clinical Gastroenterology and Hepatology was elegant and answered some serious questions regarding this disorder. The study involved 59 adults in a double blind, placebo controlled crossover study which is the best way to attempt to answer this question.

What they found was that subjects consuming small amounts of gluten had significantly more symptoms related to NCGS than the placebo group. This is proof of concept without having a biomarker to prove association. This is not proof that gluten is the sole cause of disease as much as a significant association with symptoms.

One fascinating part of this study was that some patients developed depressive symptoms during the 1 week gluten trial. The rapidity of mood symptom onset was surprising to say the least.

Lets look at another study. In 2013, a Brazilian group studied the effects of gluten in mice that were fed an obesity inducing high fat gluten diet versus a no gluten/high fat diet. These mice do not have celiac disease and are prone to become obese when fed a high fat standard chow.

The results: gluten eating mice gained significantly more weight, had blood levels of fat, cholesterol, glucose and insulin that were higher; the gluten free group had an up regulation of insulin receptors and genes like PPAR that control glucose and fat metabolism, they had elevated enzyme levels like LPL and ACC that transport and breakdown fats; Finally, they also found that the gluten fed mice had higher levels of inflammatory proteins linked to metabolic endo-toxemic derangements known to be associated with chronic diseases.

Boiling it all down. This is not a human study, however, it is clear evidence that in animals feeding gluten with a high fat diet (the American diet) causes the body to get fatter, have worse glucose control, have worse fat profiles and have increased inflammation! There is no way to spin this positively.

The inflammation is the most damning part of this research as it is the root cause of all disease.

Let's just say that you are stressed out in cortisol overload, eating like a standard American, taking antacids and antibiotics and not moving much. You get the picture.

There are no concrete human studies to prove that non celiac gluten sensitivity causes a worsening of heart disease risk, however, this animal data is a starting point for my N of 1 results.

What truly is causing this mess? Is it really gluten? Is it the micro biome and the derangements that follow a gluten/high fat diet? Is it a combination of all?

Following Occam's razor, the simplest answer is likely the right one. The combination is likely the cause as we know that refined foods are detrimental.

To be continued:

Be aggressive against disease,

Dr. M