So, you have found the right health care provider. He spent an hour with you on the first visit and really seemed to listen. He seemed thorough, as well. He ordered a battery of lab tests, and performed what appeared to be a thorough physical examination. He says he has found a possible diagnosis that explains your symptoms. Up until this point he has built up a high level of confidence and hope with you. Then the doctor leans in and, with total sincerity, indicates the lab tests were negative and your physical exam was negative. You are thinking, “Now what? I really thought this guy would be the doctor to help me. I have been to so many for my condition. Then, not to purposely interrupt your moment of despair, he exclaims, “However, I think I may have a diagnosis that is treatable and may alleviate most, if not all, your symptoms.” “Wow,” you are thinking, “How could he come up with such a diagnosis, especially with all the negative tests; can I believe him?” With a sense of hopeful wonderment you ask him what your diagnosis is. He explains, “You may be gluten intolerant.” But, what is “gluten intolerant” and how can it affect your health so negatively.
What is gluten?
Gluten is a protein found in wheat, barley, rye and other grains that some people have difficulty processing. The question I am often asked as a health care provider is, “How can I have a problem with wheat? Wheat has been part of our staple diet for the past 10,000 years.” The truth is that no one knows the answer to that question. Not yet. However, there are some theories about this. One theory is that a virus mutated a gene in the body to cause a defect in the enzyme that breaks down gluten. Another thought is that gluten, in evolutionary terms, has been introduced on a large scale in just a short period of time and that humans were never meant to eat it. Whatever the reason, some people should definitely avoid it.
People with symptoms of gluten intolerance that are related to digestion are often associated with having celiac sprue or celiac disease. These symptoms may include abdominal pain, bloating, diarrhea, constipation, greasy stool, alternating diarrhea/constipation, nausea, and vomiting. Gluten intolerance in children may lead to stunted growth, weight loss, delayed puberty, and lack of energy. People who are gluten intolerant with symptoms that are typically not associated with the gastrointestinal system are said to be gluten sensitive. Gluten sensitive symptoms may include, but are not limited to, migraine headaches, depression, anxiety, fatigue, osteoporosis, joint/bone pain, muscle cramping, infertility, canker sores, anemia, and deficiency of vital nutrients. People with Celiac may have these symptoms as well. Sometimes a person may not have any symptoms at all. This is the worst case because if gluten intolerance goes unnoticed it can be associated with leading to other medical conditions including autoimmune disorders, diabetes mellitus type 1, autoimmune thyroiditis, and biliary cirrhosis.
How many people have it?
The incidence of celiac disease in America is reported to be 1 in 133 according to the University of Maryland Center for Celiac Research. Although this number does not take into account the incidence of people who have gluten intolerance with no GI-type symptoms. That number may be higher as gluten intolerance is often misdiagnosed and may be present with no symptoms at all. To make matters worse, there is no definitive lab test that rules out gluten intolerance.
So why is gluten or the avoidance of gluten so important to those folks who are intolerant to gluten and how is this condition treated? Before we begin this story, let -998upus first visit some structures of the body and how they function normally.
A brief overview of the digestive system
When we swallow food it travels through the gastrointestinal tract (GI tract). The food travels from the mouth, continuing to the esophagus which then leads to the stomach. Following the stomach, the food then ends up in the small intestine. Nutrient absorption takes place predominantly in this area of the GI tract. Before the food particles are absorbed into the blood stream from the small intestine it has to be broken down further by enzymes. Enzyme secretion and nutrient absorption in the small intestine occur at the level of the villi. The villi are tightly packed, small finger-like extensions that extend into the small intestine. Lining the small intestine like small blades of grass, the villi are also responsible for excreting antibodies into the small intestine. Antibodies are part of the body’s army to fight off infection. To recap, the villi are responsible for the movement of nutrients into the blood stream, the production of enzymes to break down nutrients for utilization by the body, the inhibition of undigested material from entering the blood stream, and antibody excretion, specifically secretory IgA or sIgA, to fight infection.
The undigested material then travels into the large intestine were water and salt are reabsorbed and the remaining material is eliminated out of the body.
Now that we have the characters and know some key attributes, here is the gluten story.
The gluten story
In gluten sensitive individuals, gluten is not fully broken down in the small intestine by the enzyme transglutaminase. The body then mounts an attack on the partially broken down gluten creating inflammation. This inflammation is not only specific for gluten it can also wear down the villi, like grass blades being cut with a lawn mower.
As the villi are destroyed, nutrient absorption, enzyme production, and GI immunity are compromised.
Gluten as it affects GI enzyme production
The destruction of villi can lead to lactose intolerance. The reason behind this is that as the villi are eroded due to gluten intolerance, their ability to secrete enzymes becomes decreased. The enzyme involved in the process of breaking down the sugar in milk (lactose) is lactase. If lactase production is inhibited due to villi destruction then the amount of lactose broken down for absorption is decreased. This allows the lactose sugar to continue down the GI tract causing lactose intolerant associated symptoms of gas, bloating, and stomach cramping.
Gluten as it affects GI absorption
As absorption is impaired, so is nutrient transportation across the GI barrier into the blood stream, causing associated symptoms. For example, if iron is not adequately absorbed, a person may feel excessively tired. If amino acid absorption decreases then chemicals such as neurotransmitters, which are chemical messengers in the brain, may become imbalanced. In the case of compromised neurotransmitter formation, symptoms such as depression and anxiety can arise.
Gluten as it affects GI immunity
Another part of the gluten story lies within the GI tract’s ability to fight off infection. As the microvilli are destroyed, so are the cells that compose them. One of the cells that make up the villi are Plasma Cells. These cells produce the antibody sIgA. SIgA is a large part of the body’s first line of defense against invaders. It is found normally throughout the GI tract. Parasites that would normally be hindered by sIgA can have a stronger foot hold in the GI tract with decreased sIgA amounts. The presence of one type, or several types, of parasites can further compound the destruction of the villi by creating more inflammation which leads to more negative effects on the immune system, enzyme production and absorption, and the development of “Leaky Gut”.
If the previous issues are not bad enough, their lies another villain in this story. “Leaky Gut” is a result of increased permeability of the GI tract. The spaces between the cells that line the intestine are caledl gap junctions. Gap junctions are normally closed off tight. Gluten intolerance can cause the gap junctions to loosen and become open. This allows the flow of undigested material, along with gluten, to pass into the blood stream to be carried to various areas of the body. This undigested material and gluten is viewed by the body as an invader and is attacked by the body’s defenses. This can create inflammation in the body outside the GI tract. I will repeat this: Leaky Gut can cause inflammation in the body outside the GI tract. It is important because as these particles that do not belong in the blood stream settle in different areas of the body, they can create inflammation in that area. For example, if it travels to the joints it can create joint pain. If it travels to the muscles it can create muscle aches and pain. This may be why gluten intolerance is associated with autoimmune disorders such as Hoshimoto’s Thyroiditis. The liver has to clean out these undigested particles as well, leaving the liver over worked. This may show up with blood work as elevated liver enzymes. This can lead to toxin build up in the body as the liver’s detoxification systems become overburdened. In turn, this build up can lead to weight gain as toxins that would normally be excreted in bile out into the GI tract to be eliminated build up in fat cells causing weight gain.
How do I know if I am gluten intolerant?
The “gold standard” is an intestinal biopsy. Unfortunately, this test carries with it a high false negative rate; in other words, this test is not very accurate for people who are gluten intolerant. Blood, stool and saliva testing also carry a high false negative rate. These tests can be useful following elimination of gluten for 6 to 8 weeks as the immune system reestablishes itself in the gut. The key to gluten intolerance is the way a person feels after being off gluten for 6 to 8 weeks.
Treatment is the same as the test.
The most definitive test for gluten intolerance is to completely eliminate gluten from the diet for 6 to 8 weeks. It takes 6 to 8 weeks for the villi to heal. During the 6 to 8 weeks a person’s symptoms may increase at times, decrease, or stay the same. As the small intestine heals there may be periods when symptoms worsen periodically. This is caused by areas within the wall of the small intestine that were previously closed off due to damage caused by long standing inflammation. These closed off areas open up, allowing their long standing contents (sometimes parasites) out into the GI tract. These contents can make a person feel sick. As these areas heal the flare ups of symptoms should diminish. This is why a person on a gluten-free diet may exclaim that the gluten-free diet isn’t working for them. However, at the 6 to 8 week mark symptoms should be improved significantly or disappear in a gluten intolerant person. The person should be tested for intestinal parasites at the end of the 6 to 8 week time period off gluten with their healthcare practitioner. After being gluten-free for 6 to 8 weeks, reintroduce gluten with a gluten-rich meal. If symptoms return or if GI type symptoms such as gas, bloating, belching, stomach pain, diarrhea, and vomiting occur then a gluten- free diet needs to be part of your life from then on. This can be difficult because aside from the more known sources of gluten like wheat, barley, rye, spelt, and oats, there are less apparent sources of gluten found in items such as salad dressings, soy sauce, imitation sea food, beer and many other unlikely, but regularly consumed food items. A person who is gluten intolerant may want to avoid soy as some practitioners believe soy protein mimics the molecular make-up of gluten in gluten sensitive individuals. A gluten intolerant person should only consume grain type products from rice, millet, buckwheat, and corn. Also, to confuse the consumer more, products labeled “wheat free” are not the same as gluten-free. One must read nutrition and ingredient labels very carefully to discern gluten content.
There are currently no drugs or procedures to treat gluten intolerant individuals. The good news is that a gluten sensitive person can live a healthier life by avoiding gluten. In addition, there are more available resources than ever before that teach people how to live a gluten free lifestyle as gluten intolerance becomes more recognized. Also, gluten free product variety and taste continue improve as well.
If you think you are gluten intolerant or someone you know may be, I invite you to do your own research on gluten intolerance and Celiac disease.
I sincerely hope this information helps you on the path to optimal health.
Yours in Health,
Sean Ripp, D.C.