Celiac Disease

Feb 6, 2018 | Autoimmunity, Uncategorized

Celiac Disease is a serious autoimmune disorder in which the gluten protein triggers damage to the lining of the small intestine.  Gluten is the generic name for proteins in some grains. The exact reactive proteins in each of the gluten-containing grains are slightly different and have different names. Gluten is the umbrella name for these proteins. For example, the protein in wheat responsible for gluten reactions is gliadin. (Grains and Legumes Nutrition Council, 2016)

When gluten is present, the body’s immune system reacts by destroying the villi of the intestinal tract. The villi are the small fingerlike projections that greatly increase the digestive surface of the small intestine and do the work of finishing digestion and absorbing nutrition from the food we eat.  With continued damage, the small intestine loses its ability to function properly, becomes increasingly permeable, and is unable to properly absorb nutrition from food.  The ensuing malnutrition and immune upregulation lead to serious disease and even death.  There is no cure for celiac disease and it can only be controlled through a strict gluten-free diet.

Developing celiac disease, like other autoimmune diseases depends on three factors.  The first is genetic predisposition.  The DQ2 and DQ8 variations of the HLA (human leukocyte antigen) gene are genetic markers for the disease.  There is disagreement as to whether all celiacs have at least one of these gene mutations.  Some say an estimated 98% of celiac sufferers have one or both gene variations. (Ballantyne, 2013) Others say 95% of celiacs have DQ2 and the rest have DQ8 (a subset having both.) (Crowe, 2010)

These HLA gene variants cause gluten peptides to be bound more tightly and therefore make them more immune stimulating.  To make it more complex, celiac disease is also associated with 250 more genes and a lot of research is happening now to tease out all the genetic factors at play. (Gujral, 2012) Having a first degree relative with celiac disease gives one a 10% chance of having it as well.  Chances increase to 20% if a first-degree relative has tested positive via intestinal biopsy.  Risk increases up to 40% if a first-degree relative has the same HLA variation. (NCHPEG, 2016) Having the DQ2 and/or DQ8 gene defects does not mean a celiac diagnosis. In America, 35-40% carry one or both defects, while only 2-3% of those people will ever get celiac disease.  Estimates are genetics only represent 40% of the overall risk of developing celiac disease. (Crowe, 2010)

The second factor in developing celiac disease is an environmental trigger.  Unlike some autoimmune conditions, the trigger for celiac disease is well known—the protein found in gluten-containing grains.  Gluten-containing grains are wheat (including wheat varieties spelt, kamut, farro, and durum—plus products like bulgar and semolina), barley, rye, and triticale.  The protein in oats is so similar that about 1 in 5 react to oats as well.  It is also very hard to find oats that are not contaminated with gluten, so it is best to at least test them for reactivity through elimination and reintroduction.  In Australia and New Zealand, gluten-free products are banned from using oats. (Grains and Legumes Nutrition Council, 2016)

Celiac disease may have other triggers beyond gluten itself. There is some research showing that viruses and stress may also be part of the triggering mechanism.  For example, the candida fungus shares a similar protein structure with gluten and may act as the immune activator as the body mistakes the fungal threat as gluten. (Bauman, 2015) Yet another trigger in developing celiac disease may be glyphosate (active ingredient in the herbicide Roundup.)  Researchers have shown that ingestion of foods grown with glyphosate causes celiac symptoms in animal studies.  Some experts believe the use of glyphosate is the greatest causal factor in the epidemic of celiac disease and gluten sensitivity. In the US, wheat is typically sprayed with Roundup right before harvest to desiccate it.  (Samsel, 2013)

The final factor in developing celiac disease is leaky gut syndrome/gut dysbiosis.  A leaky gut is present alongside every autoimmune disease that has been tested.  All the science points to leaky gut and dysbiosis being a precipitating factor to developing autoimmune disease, celiac disease included.  Zonulin, a protein excreted by the enterocytes (cells forming the small intestine barrier,) stimulates the opening of the tight junctions in the intestinal barrier.  Those with celiac disease, type 1 diabetes, multiple sclerosis, and other autoimmune conditions test with high levels of zonulin.  Zonulin release is triggered by gluten. (Ballantyne, 2013) Intestinal permeability and gut microbiome dysfunction not only show an immune system that is malfunctioning but also open the door to immune upregulation and autoimmune disease as foreign proteins pass from the gut into the bloodstream and right into the arms of the immune cells surrounding the gut. (Ballantyne, 2014a) For celiac disease, when the genetic predisposition and the trigger are both present, and a compromised gut allows opportunity, the disease can develop.

There are over 200 known symptoms of celiac disease.  Symptoms can differ in children and adults.  To make it even more confusing and difficult to diagnose, some sufferers are asymptomatic (while suffering the intestinal damage.)  The most common symptoms for children are: (Celiac Disease Foundation, 2016a)

  • Abdominal Bloating and Pain
  • Chronic Diarrhea
  • Vomiting
  • Constipation
  • Pale, Foul-smelling, or Fatty Stool
  • Weight Loss
  • Fatigue
  • Irritability/Behavior Issues
  • Dental Enamel Defects
  • Short Stature
  • Failure to Thrive
  • ADD/ADHD
  • Malnutrition

The most common symptoms for adults are: (Celiac Disease Foundation, 2016)

  • Unexplained Anemia
  • Fatigue
  • Bone or Joint Pain
  • Arthritis
  • Osteoporosis or Osteopenia
  • Liver and Biliary Tract Disorders
  • Depression or Anxiety
  • Peripheral Neuropathy
  • Seizures
  • Migraines
  • Irregular Menstrual Periods
  • Infertility/Recurrent Miscarriage
  • Canker Sores
  • Dermatitis Herpetiformis (itchy rash)
  • Malnutrition

Those with celiac disease must adhere to a strict gluten-free diet for life.  This means avoiding all gluten-containing grains (and possibly oats.)  Gluten in health and beauty products must be avoided as well.  If it goes on your body, it goes in your body.  Following a gluten-free diet is very difficult because naturally gluten-free foods are frequently contaminated with gluten.  Items like rice, millet, and soy are often contaminated.  The standard in the US for a food to be labeled “gluten-free” is that it cannot contain more than 20 ppm (parts per million) of gluten.  In one instance, soy flour (naturally gluten-free) tested at 3,000 ppm.  Many experts call for a grain free diet as best for celiacs. (Mercola, 2010) Is the gluten level of 20 ppm in the US low enough?  At least for some, the answer is no.  If gluten causes autoimmune damage to the body, the best diet is one that contains zero gluten.  In Australia and New Zealand, the government moved to a mandate of 3ppm to be able to label an item gluten free.  When this happened, celiacs there reported greatly improved health. (Anderson, 2014)   Items labeled “gluten-free” are not necessarily great choices.  The best diet for someone with celiac disease is a whole foods diet with as little processed food as possible and avoiding grains altogether.

For some, there is a possibility of the body reading a protein with a similar structure as “gluten” and reacting to it as well.  This concept is called gluten cross-reactivity.  The foods that have tested as possibly cross-reactive are dairy (including protein isolates,) milk chocolate (not cocoa,) instant coffee, oats, millet, rice, corn, and yeast (brewers and bakers.) (Laird, 2015)

Because celiac disease means that a leaky gut is present, it is likely that other food sensitivities are present as well.  IgG food sensitivity testing can help uncover these additional sensitivities and/or an elimination diet like the Paleo Autoimmune Protocol can be undertaken (a better route.)   To completely heal the gut, all offending foods need to be eliminated with the goal of returning some of them to the diet later (not gluten of course.)

The damage done in celiac disease goes beyond the intestinal tract.  The repercussions of celiac disease, especially when it goes undiagnosed and unchecked, are serious and can be life-threatening.  Depression, ADHD, fertility problems, seizures, and migraines are a few of the symptoms/repercussions of unchecked celiac disease.  Celiacs have an increased risk of gastrointestinal, skin, and thyroid cancers.  Having celiac disease also makes it ten times more likely to develop other autoimmune disorders, particularly Type 1 Diabetes and thyroid disease. (Celiac Disease Foundation, 2016b) There may even be a link between celiac disease and schizophrenia.  There are anecdotal cases of schizophrenics being cured with a gluten-free diet.  (Deans, 2011)

Does a strict gluten-free diet heal the intestinal villi and restore complete and normal gut function?  Unfortunately, not always.  2 years of adherence to a strict gluten-free diet only showed 1/3 of patients with completely restored function.  After 5 years, 2/3 had completely restored villi.  Factors at play include the extent of the damage prior to diagnosis, gluten contamination, cross-reactivity, genetics, age, and overall diet and lifestyle. There is evidence that American celiacs recover more slowly and less completely, due to the overall low quality of the American diet and the amount of gluten cross-contamination. (Anderson, 2016a) 1.5% of celiac sufferers are eventually diagnosed with refractory celiac disease.  This means that despite a strict diet, their villi do not heal. (Anderson, 2016b) At the end of the day, celiac disease has the power to shorten lifespan via the repercussions of malabsorption and leaky gut.

I will now turn my attention to nutrients and supplements that can be used to help heal and correct deficiencies.  It is very important for celiac sufferers to get comprehensive testing done to uncover their particular needs in light of the damage to their body.

Let’s take a deeper look at three key nutrients:

Vitamin D:  Vitamin D deficiency is common but is rampant among celiacs.  Vitamin D levels are depressed in celiac disease due to absorption problems. Maintaining healthy Vitamin D levels is necessary for proper immune system function in addition to a long list of other body functions.  The high risk of osteoporosis in celiacs is due to low D levels.

Our bodies can make Vitamin D when we are exposed to sunlight. This is rarely enough to keep levels optimal and for a celiac with absorption problems in almost certainly not sufficient.  Vitamin D can be obtained from foods such as cod liver oil, fatty fish, beef liver, oysters, eggs, and mushrooms. Day three of my meal plan provides 25.16 iu of Vitamin D—not much even though pastured eggs and seafood are best sources and included on that day.  Dr. Hyman recommends 2,0000-4,000 iu to maintain healthy levels and 5,000-10,000 iu to replenish a deficiency. (Hyman, 2010a)

The normal target range in lab testing for Vitamin D levels is 20 nanograms per milliliter (ng/ml) to 70 ng/ml.  Many practitioners consider 31 ng/ml or above to be adequate.  At that level, an individual is 4 times as likely to suffer from autoimmune problems or cancer than someone with optimal levels.   Dr. Terry Wahls says 80 ng/ml is an ideal target. (Wahls, 2015) Dr. Hyman recommends a range of 40-60 ng/ml. (Hyman, 2010)

Without knowing the client’s D level through blood testing, I think it is safe to recommend 5,000 iu as a daily supplement.  The biologically active form of the Vitamin is D3 and that is the only form that should be taken.  Vitamin D is a fat-soluble vitamin and should be taken with fatty food or as a suspension in fat.  The client should have D tested to see if more supplementation is needed and try to get some sun daily.

Vitamin B12: A study in the Journal of Clinical Nutrition in 2000 stated that up to 39% of the US population may have a Vitamin B12 deficiency.  Celiacs, due to malabsorption problems, are more likely to be deficient.  Vitamin B12 is crucial for many body systems including gastrointestinal, nervous, detoxification, and cardiovascular.  Vitamin B12 improves digestive function.  Healthy nerve function relies on Vitamin B12 to maintain properly functioning myelin sheaths on nerves. Vitamin B12 deficiency can cause anemia. Mood disorders like depression and anxiety, learning and memory problems, and attention difficulties like ADHD are all possible celiac symptoms and trace their roots, in part, back to Vitamin B12 deficiency.  (Axe, 2015a)

Day three of my meal plan provides 15.67 mcg with top sources being salmon, sardines, and lamb.  Other top food sources are beef and chicken liver, other fatty fish, turkey, and grass-fed beef.  The National Institute for Health recommends 2.4 mcg daily for adults so my meal plan provides well over that.  However, since we are dealing with celiac disease and chronic malabsorption, much more is well advised.  Vitamin B12 is a water-soluble vitamin and the body easily flushes out what is not needed.  That means it’s important to constantly supply the body with it.  The need for B12 is amplified for anyone with other factors that reduce absorption.  This includes anyone that smokes, drinks alcohol to excess, has undergone bariatric surgery, takes acid-lowering drugs, and/or has taken a lot of antibiotics. (Axe, 2015a) Some pharmaceuticals, notably Metformin for diabetes, reduce B12 absorption as well.  Vegetarians, and most especially vegans, risk being deficient as well. (Mercola, 2009)

Supplementation is warranted for any celiacs showing symptoms of deficiency.  The methylated form is necessary for anyone with an MTHFR mutation and safe for everyone so use the methylated form.  It is often given as a liquid, sublingual tablet, shot, or even IV for better absorption.  To correct the deficiency, a common recommendation is 1,000 mcg daily. (Mayo Clinic, 2013)  Another option is to take it as a B complex.  B vitamins work synergistically and need each other to work well.  Thorne brand Basic B Complex is a good one.

Fiber: A high fiber diet is key to digestive health.  Fiber bulks stool and helps it to move efficiently through the intestinal tract.  Fiber is also critical for maintaining a healthy microbiome which is vital to overall health.  Celiacs often have trouble with diarrhea and/or constipation, both of which can be helped by a high fiber diet.  When gluten-containing grains are removed from the diet, they are often replaced with processed gluten-free products.  That is a mistake.  Removing gluten-containing grains (and perhaps all grains) should mean a diet even more full of fruits and vegetables.  How much fiber counts as a high fiber diet?  Recommendations range from 40 grams (Bauman, 2015) to 50 grams (Hyman, 2010b) daily.  Day three of my diet plan contains 31.22 grams of fiber so is not quite meeting the requirements of a high fiber diet.  Best sources on that day are avocado, broccoli, apple, butternut squash, salad greens, plantain, kiwi, and grapefruit.  Adding 2 Tb of ground flax seeds daily increases fiber and can help ease elimination issues.

 

Other Recommendations for Synergistic Foods, Nutrients, and Herbs:

Zinc:  Zinc is a mineral responsible for over 200 body processes—many of them immune related.  67% of those who are gluten sensitive (including celiacs) are deficient.  Zinc is also vital for maintaining the integrity of the intestinal wall.  Even 8 weeks of zinc supplementation can show huge gains in intestinal integrity.  Chronic zinc deficiency is a main reason why folks don’t heal completely and more quickly after removing gluten from the diet.  (Gluten Free Society, 2014)

The RDA is 15 mg for men and 12 mg for women.  Therapeutic doses for healing leaky gut are 50-80 mg per day, not to exceed 100 mg daily.  Above 100mg daily, zinc depresses immune function.  It is helpful to balance zinc with copper, taking 1mg for every 15 mg of zinc supplementation.

Best dietary sources of zinc are oysters, pumpkin seeds, ginger root, pecans, brazil nuts.  Zinc is less bioavailable in plant foods; therefore, animal sources are more useful here.  (Bauman, 2015)

L-glutamine: L-glutamine (also known as glutamine) is an amino acid present in many protein-rich foods.  It is the most abundant amino acid found in the body and is involved in more metabolic processes than any other.  L-glutamine is also the best compound known for improving leaky gut syndrome, which is present in untreated celiac disease.  Enterocytes in the small intestine and GALT cells both use L-glutamine as fuel.  Because of its rapid uptake by our immune system, those with leaky gut and an up-regulated immune system, need larger amounts of L-glutamine.

L-glutamine levels in foods are not labeled or easy to track.  The L-glutamine in animal sources is higher and more bioavailable.  Making bone broth, a traditionally prepared, long-simmered stock from bones, is a great way to boost L-glutamine levels naturally.

In the case of celiac disease, supplementation is strongly encouraged.  What the body cannot use will be eliminated and recommendations for supplementation vary widely—from 2-5 grams daily (Bauman, 2015) to 10-40 grams daily (Ballantyne, 2014.)  It is best to take it on an empty stomach for maximum absorption.

Probiotics: Probiotics are healthy bacteria that populate our digestive tract and our immune system needs them to function properly.  Healing dysbiosis is a large part of healing intestinal permeability and maximizing digestion.  Probiotics not only help repopulate the gut with healthy microbiota but also can help seal those leaky tight junctions between enterocytes. (Ballantyne, 2014) We can consume probiotics in the form of fermented foods as well as by supplementation.  Examples of safe anti-allergenic fermented foods include raw, unpasteurized lacto-fermented vegetables like sauerkraut, carrots and pickles; kombucha; water and coconut water kefir, and homemade coconut yogurt.  Avoid commercial yogurts that beyond being made from gut-irritating dairy, are very processed, loaded with sugar, and contain limited strains of helpful probiotics.  Try to eat at least ¼ cup of probiotic-rich foods daily.

Probiotic supplementation is very useful.   Again, recommendations for formulas and amounts vary widely.  Stool analysis is available that allows you to know what strains are flourishing in your gut and help you target certain strains in supplementation.  Remember, there are thousands of different species.  Lactobacillus and Bifidobacterium are key microbes to include in supplementation.  A good approach is to take at least 35 billion organisms a day for four weeks and then reduce to 10 billion organisms a day for another month. (Jade, 2015)

Researchers agree that variety is important. One way to introduce a wide variety of probiotics into your diet is to look at soil-based organisms.  Getting your own hands into the soil to grow and harvest that food is even better.  We live in a hyper-sterile culture.  Food fresh from the farm with a little dirt may be a great probiotic prescription. (Miller, 2015)

Digestive Enzymes:  Low levels of digestive enzymes can be a cause of and common contributing factor to leaky gut. (Jade, 2015) For celiacs, any help digesting food is warranted. Digestive bitters from foods like dandelion, lemon juice, and apple cider vinegar are a natural way to boost hydrochloric acid, digestive enzymes, bile production, liver function, and more. (Grossman, 2014)

The need for and amount of supplementation needed for digestive enzymes can also be gained from stool analysis.  Digestive enzymes help an overworked and healing intestinal tract.  A well-rounded enzyme supplement should contain: Protease – breaks down proteins, Amylase – breaks down starches, Lipase – breaks down fats and Lactase – breaks down lactose in dairy (if consuming). (Axe, 2015b)

Gelatin and Collagen: Collagen makes up 30% of our bodies—giving structure to skin, hair, nails, bones and more.  Gelatin is the cooked version of collagen.  It’s a protein made of a group of amino acids like proline and glycine which help rebuild the intestinal lining and support the health of the intestinal mucosal layer. (Axe, 2015b) They also contain glutamic acid that our body converts into L-glutamine for further intestinal healing.  I recommend the Vital Proteins brand “Collagen Peptides” and “Gelatin.”  They are sourced from grass-fed beef.   The “Collagen Peptides” is a cold water soluble supplement that can be mixed in with drinks, oatmeal, etc.  The gelatin must be mixed with hot beverages or soups.  There are no official dosing guidelines, but mixing a scoop (about 20 grams) into a beverage morning and evening is a good guideline.  The gelatin is more satiating and is a good option for evenings.  Ancient Nutrition is a line of flavored bone broth powders that can be added to anything hot or cold and are a convenient and fun way to add more protein and collagen to the diet.

DGL: This is licorice root that has had the glycyrrhizin removed.  Glycyrrhizin is a compound that has been shown to cause edema and hypertension, but this deglycyrrhizinized version helps maintain gut lining.  DGL supports the mucous lining of the stomach and upper small intestine.  It is especially helpful after an accidental gluten exposure.  In addition, DGL is an adaptogenic herb that helps regulate hormone levels. It helps in the absorption and metabolism of the hormone cortisol, thus battling adrenal fatigue and supporting gut health by helping modulate stress levels. (Axe, 2015b)

DGL can be added to the diet as a powder, supplement, or tea.  500 mg twice daily is a good therapeutic dose.

Glutenza:  Glutenza is an interesting newer supplement from NuMedica.  It was developed by Dr. Tom O’Bryan, an expert on gluten driven disease.  Glutenza is NOT designed to promote ingestion of gluten, but it is very helpful when consumed with a meal where cross contamination may occur.  Dr. Sarah Ballantyne recommends taking it when dining out because of the risk of contamination.  It can also be taken after an accidental gluten exposure but is most effective when taken with the meal.  (Ballantyne, 2016)

Glutenza is a combination of gluten-digesting enzymes, targeted probiotics, and special prebiotics.  (NuMedica, 2014) In one hour, Glutenza can break down 99% of gluten proteins, rendering them harmless to the small intestine. (Ballantyne, 2016)

 

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