Some don't recover fully on a gluten-free diet alone. Photo: CC-Evil Erin
This article originally appeared in the Spring 2010 edition of Celiac.com's Journal of Gluten-Sensitivity.

Celiac.com 10/22/2010 - More and more we’re hearing from frustrated patients who, despite being vigilant about their gluten-free diet, continue to suffer health problems.

I have been involved in the field of celiac and gluten sensitivity for over 15 years and am delighted by much of the recent increased awareness and attention given to the area.  But I’m also concerned about the lack of assistance given to many patients who have been definitively diagnosed with either celiac disease or gluten sensitivity.  While being correctly given the advice to not eat gluten, they are not provided with a follow-up program to address and treat the secondary effects of gluten sensitivity.  This oversight condemns many to ongoing ill health.

The focus of this article is on the types of conditions we see clinically with our patients, some of the recent research that corroborates our findings, and steps you can take to address the underlying root cause of these problems.

Leaky Gut

Also known as increased intestinal permeability, a leaky gut refers to a loss of integrity of the lining of the small intestine.  Recall that the small intestine is approximately 23 feet in length and has the surface area of a tennis court.

Gluten, in the sensitive individual, is a known cause of leaky gut, but in a perfect world the elimination of gluten would allow healing to occur resulting in an intact, healthy intestinal lining.

Alas, we do not live in a perfect world and other factors contribute to the health of the gut.  Infections in the form of parasites, amoebas, bacteria, and the like, can certainly contribute to continued increased permeability.  Likewise, other food reactions, chief among them dairy, can cause persistent irritation and thereby prevent healing.  Imbalance of the beneficial bacteria or microbes that comprise the microbiota of the intestine, as well as nutritional and pancreatic enzyme deficiencies, are also suspected to limit healing.

Let’s take a look at each of these individually:

Infections

Whether one has celiac disease or is gluten sensitive, one thing is for sure, one’s immune system has been overtaxed due to the presence of gluten in the diet.  Depending on the age at diagnosis, it is often several decades of stress that the immune system has undergone.

Such an overburdened immune system is unable to be as vigilant as a healthy one and as a result it allows such organisms as parasites, amoebas or bacteria to infiltrate the body.  Some estimates suggest that the digestive tract is normally exposed to a pathogenic organism every 10 minutes.  A healthy intestinal immune system is able to identify and eradicate those organisms as part of its normal activities.  An unhealthy immune system often “misses” such organisms and they happily take up residence in the small intestine.

Interestingly, some of these organisms create crypt hyperplasia and villous atrophy that appears the same as that caused by gluten.  Imagine the frustration of a patient who is being told by their doctor that they are not following their diet when indeed they are.  What’s being missed?  The presence of an infectious agent.

In the 2003 American Journal of Gastroenterology, researchers reported a large percentage of small intestinal bowel overgrowth (SIBO) in celiac patients with persistent GI symptoms despite adherence to a gluten-free diet.  These patients were off gluten, as instructed, but were still having diarrhea due inhospitable organisms in their intestines.

This segues nicely into the next area I want to discuss – dysbiosis or imbalance of the friendly bacteria in the small intestine.

Dysbiosis

The population of organisms found in the intestines of celiac patients (treated with a gluten-free diet or not) is different from that found in healthy control groups.  The ratio of good bacteria to bad was found to be reduced in celiac patietnts regardless of whether their celiac disease was active or inactive.  Because the “bad” bacteria are pro-inflammatory in nature, they can be responsible for creating some of the initial problems with celiac disease, as well as helping to perpetuate them despite following a gluten-free diet.

In the August 2009 Scientific American, Dr Fasano made a very interesting statement regarding these microbes or probiotics as relates to the age of initiation of celiac disease.  He stated: “Apparently they [probiotics] can also influence which genes in their hosts are active at any given time.  Hence, a person whose immune system has managed to tolerate gluten for many years might suddenly lose tolerance if the microbiome changes in a way that causes formerly quiet susceptibility genes to become active.  If this idea is correct, celiac disease might one day be prevented or treated by ingestion of selected helpful microbes.”

Isn’t this fascinating?  If you haven’t read the complete article I encourage you to do so, but it is sufficient to say there is scientific discussion that entertains the notion that a healthy microbiome or probiotic population is not only anti-inflammatory (a good thing to help prevent many diseases) but may actually act as a “switch” that turns on and off the expression of certain genes.

Therefore, part of our program is to examine the population of the microbiome through laboratory testing, and supplement as needed, to support a healthy anti-inflammatory population.  In the past we typically prescribed probiotics only for a few short months following the eradication of a pathogenic organism.  But in the last several years it has become clear that our patients’ clinical profile is much more stable with continued probiotic supplementation.

Dairy Sensitivity

It can be difficult to confront major changes in one’s diet.  Removing gluten is definitely a big challenge and sometimes my patients look at me forlornly when I simultaneously recommend the elimination of dairy products.  I try to encourage them by promising that organic butter is allowed and by quickly recommending my favorite coconut ice cream, as well as cheese and milk substitutes.

Contrary to the passing thought that I wish to be cruel, there is excellent documentation to back up what we’ve seen clinically for years - gluten and dairy are truly not our friends.

The majority of the world’s people are lactose intolerant.  Populations such as Asians, African Blacks, those of Jewish descent, Mediterraneans, Mexicans and North American Blacks all exceed 70% intolerance to lactose. 

Note that many drugs and supplements may contain lactose as well, so be vigilant.

Estimates suggest that we retain the enzyme to digest our human mother’s milk for 2 to 5 years and after that milk from any mammal is likely toxic because it’s too high in protein and phosphorus, making proper digestion impossible.  Human milk is very low in protein but rich in essential fatty acids.

Casein, a protein from milk, is strongly associated with allergic reactions.  Therefore putting lactose and casein together presents double jeopardy to the body.  In this country, milk contains more toxins per gram than any other food, so you can see that there’s great cause for concern.

Earlier we spoke of leaky gut.  Dairy stops the formation of glucosamine in the intestine making it one of the primary causes of leaky gut.

I could expand on this further but perhaps we’ll save that for a future article.

Nutritional Deficiencies

When we eat, the ultimate goal is that the food will be broken down into components that can be assimilated into the bloodstream and delivered as fuel to all our trillions of cells.  Discovering that one is sensitive to gluten and eliminating it goes a long way toward achieving this goal.  However, some vitamins and minerals should be tested to ensure that their levels are normalizing on a gluten-free diet.  Otherwise good health may be a fleeting target.

Folic acid, vitamin B12, Iron and Vitamin D levels are all very important to measure.  Supplementation is often needed to optimize the levels of these substances.  Follow-up testing ensures that this objective has been achieved or maintained and should be part of a comprehensive program.

Discovering that you’re gluten sensitive and following the diet should be rewarded with dramatically improved health.  If that is not the result, other problematic factors need to be isolated and treated.  Such a program is not difficult and is well worth the effort.

Please let me know if I can answer any further questions.

To your good health!

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