Monday, May 23, 2011

Gluten Contributes to Irritable Bowel Syndrome Even in Non-Celiacs

Someone, Dr.Elena Verdu wondered if gluten might contribute to IBS and she did a study. She's discovering what others have discovered, that there is an entity, "non-celiac gluten sensitivity" where people who don't fit the diagnosis of celiac, get better on a gluten-free diet. I know it's real. It has a higher rate of morbidity and mortality, compared to the general population, according to Ludvigsson. He says:"Patients with mild inflammation and gluten sensitivity have a higher risk of death, even if their symptoms are not severe enough to warrant a diagnosis of full-blown celiac disease."

As for the notion that non-celiac gluten sensitivity is milder than celiac disease, Anderson et al, in their study titled “Malignancy and mortality in a population-based cohort of patients with coeliac disease or ‘gluten sensitivity’ World J Gastroenterol 2007 January 7; 13(1): 146-151, report a higher rate of malignancy and early mortality among those with non-celiac gluten sensitivity than among those with celiac disease.  This finding may be the result of the common recommendation that patients ignore test results that show non-celiac gluten sensitivity, as many physicians believe that such results are “non-specific” and do not warrant a gluten free diet

Let's hope there are more studies to help us sort things out. This study is reported by Diana Gitig PhD at 05/18/2011

“Irritable bowel Syndrome (IBS) is based on a clinical description only; there are no pathophysiological pathways definitively associated with it. It is characterized as gastrointestinal symptoms with no discernable cause. A diagnosis of IBS depends on recurrent abdominal pain or discomfort for at least three days per month in the last three months, with the onset of the discomfort either associated with a change in frequency or appearance of stool or alleviated by defecation. A number of different mechanisms have been suggested as potential causes of IBS. These range from psychological origins, to increased visceral hyperalgesia (sensitivity to pain), to the low grade gut inflammation and altered gastrointestinal permeability and motility observed in IBS patients. Complicating matters is that most patients exhibit only a subset of symptoms. Since gluten has been demonstrated to negatively affect even people without celiac disease by an unknown mechanism (see Study Shows Gluten Intolerance Without Celiac Disease), and the underlying causes of IBS remain unclear, Dr. Elena Verdu wondered if gluten might contribute to IBS.

Like those with IBS, patients with gluten sensitivity lack the antibodies against tissue transglutaminase that are the hallmark of celiac disease but nonetheless suffer immune mediated inflammation in their gut. Interestingly, when IBS patients without celiac eliminated gluten from their diet, 68% of them reported more severe pain, bloating, and tiredness upon gluten rechallenge. But how?  By what mechanism? No changes were detected in intestinal permeability or fecal lactoferrin, a marker of intestinal inflammation. However, it is possible that these phenomena persisted, just at below the level of detection.

Based on these data, and other evidence that is rapidly accruing suggesting that gluten can negatively affect those without celiac disease, Dr. Verdu suggests that IBS patients might be screened for anti-gliadin antibodies even if they lack antibodies against tissue transglutaminase. These nonspecific antibodies can indicate an immunological response to gluten, and thus their presence could used to determine if their symptoms might be alleviated by adherence to a gluten free diet. She makes sure to point out, though, that this is probably not the case for all IBS patients.

Read the abstract here Am J Gastroenterol 2011; 106:516–518

Intestinal Permeability
The trigger for so many diseases caused by gluten sensitivity appear to come from "intestinal permeability" which is found at the microscopic level. With or without villous damage. Here is a schematic representation of "intestinal permeability" and look at the bottom and see the influence on the immune system especially Th2CD4 and it's effects on Mast cells and ultimately the brain.

Esophageal Cancer risk doubled in Bisphosphonate (Fosamax,Actinel) use if over 5 years.

This result is reported from the team of Green J, et al from Cancer Epidemiology Unit, University of Oxford, Oxford OX3 7LF published in BMJ.  2010 September 1; 41:c4444. This particular study in the British Medical Journal involved 80,000 patients tracked for more than seven years on average.  This documents the long-term harm of these very toxic, inflammation producing drugs that do not build or rejuvenate healthy bone but poison osteoclastsSo why am I discussing this …….on a celiac blog. What if most osteoporosis cases are undiagnosed celiac/gluten sensitive persons? What if treatment of osteoporosis is the testing for celiac and if found to be so, a gluten-free diet and supplements? And if not celiac, prescribe a trial of a gluten-free diet and supplements and monitor.

But osteoporosis rates are extremely high especially in undiagnosed celiac. And remember there are 10- 13 undiagnosed persons with celiac for every one diagnosed. So gluten-eating persons with celiac disease, already prone to GI cancers and osteoporosis, are often treated with a bisphosphonate drug such as Fosamax and Actinel. And, because of their poor effectiveness, a finding reported in a January 2008 issue of the Annals of Internal Medicine (full article here), gluten sensitive people end up using them for long periods of time.
Cancer rates, especially GI cancers, are reportedly much more common in persons with celiac (and I assume those with gluten sensitivity too) who are eating gluten and within the first 5 years of stopping eating gluten. (The exact rate is difficult to nail down due to poor reporting of the diet in the groups studied, but let’s say 2-4 times higher than the normal population, according to Dr. Farrell, NEJM, 2002). Studies have shown cancer rates decrease to normal rate of 1, after five years of a gluten-free diet.

And what if bisphosphonates are not the first line of therapy for osteoporosis? So says a University of Illinois study which finds that an effective first course of action is increasing dietary calcium and vitamin D or taking calcium and vitamin D supplements.
For many people, prescription bone-building medicines should be a last resort,” said Karen Chapman-Novakofski, a U of I professor of nutrition and co-author of a literature review published in a recent issue of Nutrients, May 2011.

If a person knows they have celiac or gluten sensitivity they must only bisphosphonates as a last resort after trial of supplements as described below and a gluten-free diet. There are many other hazards of bisphosphonates including the direct side effects of osteonecrosis of the jaw, atrial fibrillation ( which requires long term use of blood thinning drugs to prevent strokes), pain syndromes and inflammation of the esophagus. See Byron Richard’s excellent summary of the hazards of bisphosphonates found here, atThe Delusions of Bone Drugs". 

Also it is well known that a gluten sensitive/celiac person who stops gluten ingestion will gain about 4% bone per year, just by that one maneuver. Adding good food, supplements of Vitamin D, calcium, magnesium, boron and strontium oratate also helps to bring the bone growth up to 20% per year (my personal observation in my patients).

Dr. Gaby's book "How to prevent and treat Osteoporosis" is wonderful resource and can be purchased at any book store.

Oesophageal cancer is not common in Western countries, but it has a high morbidity and is often fatal. On the basis of incidences for Europe and North America published by the World Health Organization in 2007,6 a doubling of risk of oesophageal cancer associated with about five years’ use of oral bisphosphonates would mean an estimated overall increase in incidence of oesophageal cancer in people aged 60-79 years from 1 case per 1000 population over five years in both sexes combined (in women 0.5 and in men 1.5 per 1000) in non-users to 2 cases per 1000 over five years (in women 1 case and in men 3 cases per 1000) in users.
If confirmed, an association between use of oral bisphosphonates and risk of oesophageal cancer would add to our knowledge of the risks and benefits of use of oral bisphosphonates. Treatment and prevention of osteoporotic fracture is a subject of increasing public health importance with large scale clinical and economic implications. Further research is warranted to confirm or refute our findings and in particular to examine the associations between use of different types and formulations of bisphosphonates and risk of the different histological types of oesophageal cancer.

Even one prescription for any type of bisphosphonate drug increases the risk of esophageal cancer by 20%.  However, when a person fills 10 or more of these prescriptions for longer than a three year period, which is standard medical protocol, then the risk doubles (200%). 

With osteoporosis, think celiac/gluten sensitivity!

Saturday, May 21, 2011

Higher Rates of Celiac Disease in People with Multiple Sclerosis -5-10 times!!!

Is Celiac disease a "Brain" disease? Is Gluten sensitivity more commonly a brain disease than an intestinal disease, in this case villous atrophy? Here is more evidence that this may be so. And it may be due to increase levels of circulation auto-antibodies as is found in this study.

The study by a team in Spain, helps us understand the prevalence of celiac disease (CD) in a group of MS sufferers- 11.1%, but the team rightly questions both the myth of the typical presentation of the adult celiac victim (most don't have diarrhea), and the emphasis on the small bowel biopsy as the only means of diagnosis. I too don't think small bowel biopsy is the only means of diagnosing CD.

They don't report how many, if any, of their patients with a normal biopsy and positive serology were asked to go on a gluten-free diet, and how many improved on a gluten free diet.  They did recommend such a trial for 6 months to rule out CD. (This group would be "non-celiac gluten sensitivity" if they responded positively to the diet (and supplementation of nutrients, especially B vitamens and vitamins D)). Perhaps they will do this study in the future.
They rightly assessed first degree relatives and found a prevalence rate of 32%!

Jefferson Adams comments on the study in 05/11/2011 - People with multiple sclerosis and their first-generation relatives have higher rates of celiac disease than the general population, according to a report by a research team in Spain.

For the study, a research team led by Dr. Luis Rodrigo of University Hospital, Central Asturias, Spain looked at rates of serologic, genetic, and histological disease markers in 72 multiple sclerosis patients and 126 of their first-degree relatives. They then compared the results against data from 123 healthy control subjects.
The team found rates of celiac disease among multiple sclerosis patients that are 5 to 10 times higher than rates for the general population worldwide, which average between 1% and 2%.

The team found similar levels of HLA-DQ2 markers in both multiple sclerosis patients (29%) and controls (26%) (NS). They found eight multiple sclerosis patients (11.1%) who showed mild or moderate villous atrophy (Marsh III type) on duodenal biopsy. Results also showed that 26 of 126 first-degree relatives (32%) had celiac disease.Multiple Sclerosis patients also displayed increased frequency of circulating auto-antibodies such as anti-TPO in 19 (26%), ANA in 11 (15%) and AMA in 2 (3%).

The authors write:
"The findings from duodenal biopsies are still considered by most experts as the "cornerstone" or the "gold standard" for diagnosis of CD. However, this statement emphatic as it may sound, is currently being challenged, especially if we take into account the adult forms of CD. In cases with very high levels of anti-TGt-2 antibodies (>100 U/ml), the duodenal biopsy may be avoided, since in most cases (> 90%) such high levels are associated with the presence of villous atrophy [30]. When the histological results are normal, but the serology is positive and the clinical picture is suggestive of CD, the diagnostic uncertainty remains, and in such cases a gluten-free diet (GFD) could be recommended for at least 6 months, before definitely ruling out a CD."

Monday, May 9, 2011


We really need to get more celiac's diagnosed to reduce the global financial, social, individual costs of celiac disease.
According to Luigi Greco (coordianator), European Laboratory for Food Induced Diseases (ELFID), Naples, Italy, Europe and the Middle East is not prepared for the burden of CELIAC DISEASE.
-the incidence is 1-44%( in at risk groups)
-the rate of undiagnosed is very high ranging from 7- 13 not diagnosed for everyone diagnosed. Some say 3% only are diagnosed.
-health care costs of an undiagnosed celiac is astronomical, being estimated at more than 5 Billions Euro/year.
-and health care costs are reported to decrease by 30% after diagnosis.
-death rate's for celiac's is 1.8 or almost double.

The aim of his teams work is to estimate the global burden related to undiagnosed Celiac disease in the Mediterranean Area, as computed by morbidity, mortality and crude health cost.

He writes:
Recent epidemiological studies show that the prevalence of Celiac disease (CD) had been underestimated, affecting not only Europeans, but also populations of the Mediterranean countries, such as Middle East (1-4) and North Africa(5-7), where its prevalence is similar to that of Western countries. Now CD appears to be a widespread public health problem, involving also the population of developing countries as well as of China (8,9,14).
In the Northern Africa Region and in the Middle East very high incidence of CD has recently been reported both in the general population and in at risk-group. These high frequencies are due to the wide consumption of wheat and barley and to the high frequency of the DR3-DQ2 CD predisposing haplotypes in these population (13,14). Prevalence of CD among low risk populations varies from 0,14% to 1,17% (15-17): 1%-1,3% in Turkey (18,19), 0,6%-0,96% in Iran (20-21), 0,5% in Egypt (22), 0,6% in Tunisia and Israel (23-24), <0,5% in Jordan, Lebanon, and Kuwait (1,10,16,25). Among high risk groups (patients with positive family history, insulin dependent diabetes mellitus, thyroiditis, etc) the prevalence of CD ranges from 2,4% to 44% assessed by serological markers and biopsy (26-27).
The use of wheat and other gluten-containing cereals is spreading all over the world, the consumption of wheat based pasta is increasing in Europe but also across Mediteranneum, where many countries are big producers also. The Italian nutritional style associated with the healthy features of the Mediterranean Diet was the cultural background supporting the widespread diffusion of the pasta. Unfortunately the side effect of this positive move has been the enormous increase of gluten intolerance.

Robust estimates of a prevalence of 1:100 individuals result in more than 5 millions individuals from the Euro-Mediterranean Countries affected by permanent gluten intolerance (Celiac Disease).
We also are aware that less than 1 every 7 adult individual and less than 1: 5 children affected are correctly diagnosed and treated (1,10-12). In the next 10 years we have to face about 5 millions cases in the Mediterranean area. This is the largest global epidemic of food-induced permanent disease in the area.
The health toll of this ‘epidemic’ unfortunately includes growth failure, infant malnutrition, gastrointestinal diseases, anemia and more than 20 associated symptoms and conditions. The risk of cancer in undiagnosed adults is significantly increased and the mortality is doubled in the total cohort of affected (28-33). The financial burden of this specific food related problem has to be estimated to more than 5 Billions Euro/year.
Very few countries from the Euro-Mediterranean Region are able to face this expanding problem : in many countries few cases are recognized, because of the low awareness and know-how to deal with the problem.
The diagnosis of CD brought a 30% reduction in direct medical expenditure. A similar 30% reduction in direct medical cost after diagnosis of CD was also reported by Green (35, 36).

There is more interesting information, including the references  here:

Wednesday, May 4, 2011

Management of Celiac Disease by Dr. Sidney V. Haas, A review by Kat

Over at , Kat writes a review and a summary of some of the important contents of the book by the Dr's Hass's. It emphasizes the basis of the treatment for celiac disease is a diet, and that diet has to be healing to the digestive tract. The most healing diet is careful not to have the wrong carbohydrates.
It is now known as the Specific Carbohydrate Diet, and refined by Dr. Natasha Campbell-McBride as the Gut and Psychology Syndrome diet (GAPS Diet). I have recommended both and only in rare occasions have I seen people thrive on any other gluten-free diet. GAPS diet works on so many different levels: lowers dysbiosis, lowers gut inflammation, heals the lesions, increases absorption of macro and micronutrients, lowers incidence of food allergies, lowers incidence of metabolic syndrome or Syndrome X and the resultant obesity, and so much more.
I just finished reading the
Management of Celiac Disease by Dr. Sidney V. Haas, the creator of the Specific Carbohydrate Diet, and his son, Dr. Merrill P. Haas. I found this book really interesting and packed with information. I took pages of notes but hope to summarize a bit more concisely here and then list some things I found most interesting to people following SCD now.
The authors cover a lot of the research on celiac disease up until the publishing of this book in 1951. At the time, gluten was not known to have any role in celiac disease (or maybe even gluten was not discovered yet) so a lot of the research done at the time was in the form of case studies using different dietary methods. It’s no surprise to me that Haas’ diet ended up having the most favourable outcome, since it is inherently gluten-free and provides adequate nutrition for someone recovering from celiac disease. I found this book quite easy to read without having any medical knowledge, so for anyone with celiac who is interested in reading about it, I highly recommend this book. (I bought mine from Digestive Wellness).


Monday, May 2, 2011

Celiac Disease Prevents Recovery from Depression

"Undiagnosed celiac disease could be getting in the way of your recovery from depression".
So says Dr. James Greenblatt, MD, Chief Medical Officer of Walden Behavioral Care in Waltham Massachusetts, a psychiatrest and Assistant Clinical Professor at Tufts University Medical School, Department of Psychiatry.He goes on to write in his blog called The Malnourished Mind:

The health consequences of celiac disease, however, extend beyond gastrointestinal issues and may affect every organ system, including the brain.
Other consequences of celiac disease include:
  • Anemia
  • Anorexia
  • Arthritis
  • Behavioral changes
  • Depression
  • Fatigue
  • Infertility
  • Joint pain and inflammation
  • Migraine headaches
  • Missed menstrual periods
  • Numbness and tingling of the hands and feet
  • Osteoporosis
  • Seizures and other neurological problems
  • Skin lesions
  • Tooth decay and discoloration
  • Weakness
  • Weightloss
Researchers have long observed an overlap between patients with celiac disease and patients who are depressed. Adolescents with celiac disease have a 31% risk of major depressive disorder, while only 7% of healthy adolescents face this risk.
But what does a disease that directly affects the small intestine have to do with a lingering sadness or listless mood? The answer is plenty. The intestinal damage wrought by celiac disease prevents absorption of essential nutrients that keep the brain healthy, especially zinc, tryptophan, and the B vitamins.

I encourage my patients with depression to be tested for celiac/gluten sensitivity disease with either a blood test or the stool tests and genetics offered at