Celiac.com 03/02/2018 - When I was diagnosed as having celiac disease with severe dermatitis herpetiformis (DH) I was told that the diet was difficult to follow and I would have to be vigilant or Dapsone would not relieve the itching. I suffered abdominal pain, outbreaks of sores, anaemia, and, (big swallow) the horrible bowel disorders. I came out of the dermatologist's office with a prescription for Dapsone to treat the attack of sores on my scalp, on my arms and thighs, along with a slip of paper referring me to the dietician at our local hospital. But that was years ago. My journey has been an ongoing trial of trial and error.

I was just discharged from hospital again, my third occasion in ICU within the past year. I have been told I am the only person in Langley who can wear that crown, the one of having Methemoglobinemia. {lucky me!}

This could happen to any celiac with dermatitis herpetiformis who takes Dapsone. And anyone regularly eating packaged meats or bacon, for instance, along with having Zylocaine injections, is at significant risk of methemoglobinemia as well. A person with celiac disease may or may not have dermatitis herpetiformis. Many celiacs go their entire lives without a DH spot on their bodies {you Lucky people}.

I have learned a lot in this past two weeks, both while hospitalized and from subsequent research, about the reasons it happened and the dangers of it happening to me again. I can never have more than one Dapsone again and I must now have methemoglobinemia tests done every six weeks. It is likely that they cannot use Methylene Blue to treat me again, unless I am at a critical point, because of the danger of the poison still being in my system.

**A little lesson here on methemoglobinemia:
Hemoglobin is the molecule in red blood cells that distributes oxygen to the body.

Methhemoglobinemia can either be inherited or acquired. It is a blood disorder in which an abnormal amount of methemoglobin, a form of hemoglobin, is produced. Methemoglobin cannot release oxygen.

There are two forms of Methemoglobinemia. The acquired form is caused by exposure to some chemicals and/or drugs and is thought to be more common than those that are inherited.

Chemicals and drugs that trigger methhemoglobinemia include:

• Anaesthetics such as benzocaine and Xylocaine
• Benzene
• Certain antibiotics {including Dapsone and chloroquine} Moi!
• Nitrites {used as additives to prevent meat from spoiling)!!

There are two sub-groups of inherited methemoglobinemia, type 1 and type 2.

The symptoms of acquired methemoglobinemia include:

• bluish coloring of the skin
• headache
• fatigue

I did not get "bluish coloring of the skin", even though I was hospitalized on three occasions with this condition and was asked about it repeatedly. I did get full frontal, severe headaches, and I did experience breathlessness when climbing stairs. I had to stop at the top of our the stairs in our home to catch my breath. My most recent admission to the Emergency Department was after such an experience. I was really out of breath, had chest pain, and my headache was so severe that I told my husband that I thought that methemoglobinemia was coming back again.

I made the mistake of following a physician's instructions - some don't seem to know that this condition can become critical.

The admissions last year were because I had two of the diagnostic criteria for Type II methemoglobinemia. I had a trapped nerve in my neck and my husband had been trained to give me Zylocaine injections to alleviate severe stabbing pains just above my right eyebrow. (The nerve travels over the head to just above the eye.)

I had been told that when I was in the throes of a dermatitis herpetiformis outbreak I could go 5 - 4 - 3 - 2 - 1 with Dapsone and Prednisone. On the first day I took 5 tablets, the second day 4 tablets, and so on. If the spots kept re-occurring then I was to follow the same procedure once more.

When I was discharged last year I was not told to change that protocol. In February, I found myself inundated with dermatitis herpetiformis spots all over the back of my head, backs of my arms and shins. I was conservative in my approach to Dapsone and took only Three Dapsone tablets on two successive days.

This set me on the path to another hospital admission. I could not climb our stairs without leg pains and becoming breathless. I had frontal headaches and just "did not feel well".

On one of my last admissions to the intensive care unit, my methemoglobinemia was 29 and the Internist treating me said that if I had sat at home with my oxygen bottle for another week my methemoglobinemia scale could have climbed to 35 which usually means death.

What to do if you develop the same symptoms: Call your health care provider or emergency services (911) immediately if you have severe shortness of breath and you have previously experienced methemoglobinemia.

Prevention: Genetic counseling is recommended for couples with a family history of methemoglobinemia who are considering having children.

After this most recent outbreak of DH I was determined to find out what had caused this last admission to hospital. It was not fun to have my blood drawn daily. Neither was it fun to have the phlebotomist coming in to draw blood gases from my wrist (ouch!) also daily. It was scary when they told me that my hemoglobin was declining daily and when it hit 80 they started the IV drip of two units of packed red cells again.

They did not do the Methylane Blue flushing during this admission because my methemoglobin was 11, not 17 or 29. Methylane Blue is a poison and they had to check with St. Paul's Hospital in Vancouver in order to determine the amount to be used on this little body. Plus they cannot keep doing this poisonous flushing every nine months. I was told this by a specialist wearing his sternest facial expression, obviously in order to scare me.

Who knows what amounts still stay in the system? Methylene blue may be dangerous to patients who have or may be at risk for a blood disease called G68PD deficiency and should not be used by them. If you or your child has G6PD deficiency, always tell your health care provider before receiving treatment.

Another interesting note is that ascorbic acid can also be used to reduce the level of methemoglobin. I don't know much ascorbic acid is required but I intend to find out. Oranges contain ascorbic acid do they not? The normal methemoglobinemia scale is about minus 0.1. Mine seems to stay at about 3.

This specialist physician also told me that I could no longer increase my dosage of Dapsone. It has to stay at one per day no matter how severe the outbreak. I must also take Cimetidine, a drug that is usually used to control excess stomach acid. It helps to reduce the impact of Dapsone on methemoglobin.

Dapsone is the dangerous drug for methemoglobinemia, and Zylocaine injections also pose similar dangers. After my admission to hospital last May, I found out that phosphates can also add to the level of methemoglobin. There are phosphates in packaged meats, with lots of those little guys in bacon and cured ham. Were I to double up on Dapsone because of a particularly bad DH outbreak, have a few injections of Zylocaine, then add some back bacon and packaged cold cuts, I might well be back in hospital with elevated levels of methemoglobin.

This time I also discovered that phosphates are sometimes in chewing gum, malted milk drinks, drinking chocolate, baked beans, instant coffee, curry powder, white pepper, some lipsticks, gravy browning, self basting turkeys, brown rice syrup, supplements and, of course, luncheon meats.

Fifteen years ago I was told I could use Atarax for the itch. Now they tell me that this drug is not only very sedating, thus slowing the heart down considerably, it is a poison that can cause tardive dyskinesia, a potentially irreversible form of brain damage. Again, fifteen years ago it caused me to experience facial gesticulations, tongue protrusion, hands that trembled and a speech pattern that often defied translation. That was because I was wrongly prescribed Loxapine for the itch, and along with Atarax, it ruined my life forever.

Misunderstandings persist. Celiac disease can look like Crohn's disease. It can look like colitis. It can look like irritable bowel disease, and because physicians have been taught that celiac disease is very rare and they often simply write it off as irritable bowel syndrome when they cannot find the cause of a GI problem. They forget that it could be celiac disease. It is just under-diagnosed, and peri-menopausal women suffer the most because they are often labeled as "depressive", or worse yet, "neurotic". I was told when working as a nurse that "irritable bowel" often meant "we just don't know".

The world has yet to define a universal "gluten-free" standard. For international trade purposes, the Codex (WHO - World Health Organization), Committee on Nutrition and Foods for Special Dietary Uses is in the process of revising their standards. At this time they are unable to reach a consensus. {Hey, this has been since 2008 and it's already 2012! What do they do at these Forums?} The Food Allergen Labeling and Consumer Protection Act (FALCPA) has committed to defining "gluten-free" for labeling purposes by 2008. We still do not have a World standard. FDA (Food and Drug Administration) acknowledges that the situation needs to be rectified and it has made a start by including gluten with other major allergens in their ingredient disclosure requirements.

The greatest progress is among the health declarations on restaurant menus and whole foods markets. Wal-Mart have also cast their lot with this group, establishing entire sections dedicated to gluten-free foods. We are finally starting to get rid of ‘stealth glutens' - those in flavor carriers, binders, fillers and emulsifiers, and used in everything from salad dressings to self-basting turkeys. We have come a long way, but we still have miles to go in reforming the food industry. As a waiter said to my friend when she told him she has celiac disease: "We don't serve fish in our restaurant, in fact we have nothing out of the sea".

References:

• DeBaun, MR - Frei-Jones M Vichinsky E Hereditary methemoglobinemia in Kliegmann RM, Behrmann RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics 19th ed. Philadelphia.
• PA Saunders, Fernandez Frackelton M Bocock, J. Cyanosis In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine Concepts and Clinical Practice 7th ed. Philadelphia, Pa, Mosby Elsevier; 2009, chap, 29.
• "Keeping Food Safety in the Mix: Food Safety in Grain Based Foods and Bakery Products" Gluten-Free Formulation, Kim Decker

Celiac.com 02/22/2018 - I am writing this article hoping to help those who have been diagnosed with gluten intolerance but who are still not feeling well, as well as for those who need to be diagnosed or will be in the future.

Just to clarify our terms, I use 'gluten intolerance' as an umbrella term to encompass both celiac disease and gluten sensitivity.

I have the privilege of speaking with many individuals, on a weekly basis, who not only live in the locality of my clinic but also those who live across the United States and internationally. Just a few days ago I had phone consultations with individuals living in Shanghai, Philadelphia and Los Angeles.

My clinic, HealthNOW Medical Center, is a destination clinic where we treat individuals who live at a distance as well as those who live nearby, hence these particular calls. As a result of doing such consultations and receiving responses to my lectures, books, blogs and videos, I have an opportunity to speak with many people and hear their stories.

Frankly I often wish I had the ability to 'beam them up' utilizing the fictional technology from Star Trek—it would make travel logistics a piece of cake and I'd be able to help more people faster.

Getting back to reality, I want to review the most common mistakes and misconceptions that I run into with people who are gluten intolerant. These miscues are resulting in ill health both currently and in the individual's future.

Here's a list of 10:
1. People who are pretty convinced of their sensitivity based on their own experimentation but who later abandon their own knowledge when a celiac test is negative.

Discussion: Firstly, they should know that celiac testing is not highly sensitive. If it were, we would be diagnosing more than 5% of the celiacs in this country.

Secondly, a negative celiac test is NOT an absolute indicator that one doesn't have the disease, it in no way tests for gluten sensitivity, a serious condition affecting likely fifteen times the number of people who have celiac disease.

Finally, the gold standard test that we utilize here at HealthNow is one that has been established by other researchers to be quite reliable. It is the very test that this person is now ignoring. Namely, eliminating gluten for 30 days to see how you feel. A noticeable improvement in symptoms is a valid test.

Too often I speak with people who are quite seriously ill. They have ignored, sometimes for years, something they knew to be the truth simply because an insensitive lab test didn't corroborate their own identification of gluten intolerance.

Don't ignore the knowledge you possess about your body. If you need a lab test to affirm that knowledge, there's always genetic testing for both celiac disease and gluten sensitivity. Entero Labs has a good test for both.

2. Some people discover they are gluten intolerant by self experimentation or by actually receiving a gluten sensitivity or celiac blood test that has positive results. Unfortunately some doctors have antiquated data regarding these diseases and believe that an intestinal biopsy is needed to confirm a diagnosis.

Such doctors insist that their patients reintroduce gluten into their diet for a minimum of six weeks and then schedule an intestinal endoscopy and biopsy.

Discussion: It was once thought that a biopsy was the 'gold standard' for celiac diagnosis. We now know that to be untrue. When I say 'we' I am referring to those in the field who research or who stay on the cutting edge of research. Unfortunately there are many doctors who are not in this category and their lack of current knowledge puts their patients at great risk.

I cannot tell you how many times I have spoken with individuals who have reintroduced gluten into their diets, despite their knowledge of how sick it would make them, only to get extremely ill, sometimes for months. Worse still, some patients initiated an autoimmune disease due to the reintroduction that we couldn't completely reverse.

I call reintroducing gluten 'Russian roulette'. Perhaps you can now appreciate why.

One should NEVER EVER reintroduce gluten once they know they are sensitive to it, regardless of any test result. There is no test that is 'worth' risking your health over, especially not for a biopsy that is very poor at identifying the presence of non-classical celiac disease and gluten sensitivity.

That brings up some new terminology:
Classic celiac disease describes the disease as it was originally described as primarily digestive in nature, and associated with destruction of the lining of the small intestine. We now know, through research, that classical celiac forms a minority of celiac cases. Once again, these data are not well known in the medical community, which explains why we miss 95% of those who suffer from the disease.

Gluten sensitivity is an intolerance to gluten that is not associated with the destruction of the lining of the small intestine but it creates inflammation through the immune system and creates many of the same diseases and symptoms associated with celiac disease. Conservative estimates of the incidence of gluten sensitivity put it at 15% of the population, making it much more prevalent than celiac disease. Assuming other factors, an intestinal biopsy would not be positive in an individual with gluten sensitivity.

3. Individuals who try the gluten-free diet and find it difficult and decide to limit gluten instead of eliminating it, thinking that less gluten is bound to help.
Discussion: Unfortunately, whether you have celiac disease or gluten sensitivity, gluten consumption requires a zero tolerance policy. I like to tell patients that consuming gluten is a qualitative factor not a quantitative one. In other words, ANY gluten is problematic.

It does make intuitive sense that more of a toxic substance is bound to create greater harm than less, but with gluten intolerance that doesn't happen to be the case. It doesn't require much gluten to begin the cascade of inflammation that can create one of the more than 300 diseases and conditions associated with it.

4. A person does not exemplify the classic symptoms of celiac disease (see point #2 above for a definition) and therefore gets no cooperation from their doctor for appropriate testing.

Discussion: This scenario can result in many different repercussions. An individual can strongly suspect gluten intolerance based on observing their body's reactions to it, but due to the absence of classic digestive symptoms, their doctor refuses to test them and, worse yet, persuades them that gluten could not possibly be a problem!

This one frustrates me because the person knows, without question, that gluten is the culprit but they allow a clinician who is operating from a dated knowledge base, to cause them to doubt themselves, and, as a result, the patient damages their health even further.
I truly cannot tell you how often I hear such stories. These individuals feel completely adrift and helpless because they literally don't know where to turn for help. I'm glad when they find our clinic and we can validate what they know to be true and really get down to work to improve their health.

5. There are some individuals who cannot 'feel' the effects of cheating and due to this they continue to cheat and eat gluten.

Discussion: This is a tough one because it is human nature to avoid things that make us feel badly but it's more difficult if there are no obvious effects.

Someone who has been diagnosed as gluten intolerant is having a reaction to gluten and it is shortening their lifespan and moving them closer to disease, each and every time they cheat.

In the past, here at HealthNOW, we have used laboratory testing to 'show' patients that their immune system was registering their cheating and thereby (hopefully) convince them that damage is being caused.

Fortunately a new lab test by Cyrex Labs is due to be released this summer (2012) that will go a step further. This test will reveal if an autoimmune disease is being created as a result of consuming gluten and what part of the body is being targeted.

We may not 'feel' diseases in the making, so this test will be a wonderful asset to educating patients about what consequences they may be bringing on themselves as a result of their lax diet.

6. Some people 'cheat' expecting something dramatic to occur within a few hours and when it doesn't they think they are okay to cheat occasionally.

Discussion: This really is a point of poor education on the part of the doctor, their patient or both. We put in a lot of time with our patients to ensure that they understand that a reaction to gluten can occur within hours or days of ingesting it. We do our very best to ensure that patients understand that a headache or rash (as an example) that appears two days after a gluten 'cheat' is a reaction to that dietary indiscretion.

We also strive to ensure that they understand that the damage goes way beyond the symptom that they feel. It goes deeper to the degree that they are likely creating a degenerative or autoimmune disease with their lax diet.

7. I hear too many stories from people who actually received a positive blood test for celiac disease but who were then told by their doctor that the test was not 'for sure' and instead the doctor decided to concentrate on a different disease the patient had rather than prescribe a strict gluten-free diet.

Discussion: The above may strike you as a little unbelievable. I only wish it was. I don't know if certain clinicians just don't feel comfortable asking their patients to follow a diet that they might not want to follow, or what exactly the issue is. But the above scenario has come up often.

To add insult to injury the disease process that the doctor has decided to focus on rather than the celiac disease is often a disease CAUSED by gluten!

I distinctly remember a young adult woman who was told by her endocrinologist that they were going to focus on her diabetes rather than her celiac disease because it would be 'too much' to address both. There is strong research evidence of the correlation between celiac disease and diabetes, not to mention the fact that untreated celiac disease is known to increase the risk of death from all causes.

8. Individuals with known gluten intolerance let 'peer pressure' cause them to cheat.

Discussion: You might think that I'm only talking about children here but I'm not. As a matter a fact I often find my younger patients to be quite disciplined. Adults, however, do at times suffer from 'not wanting to be different' or 'not wanting to be rude' and they solve their dilemma by cheating.
My advice here is to explain to the person urging you to cheat that gluten is like rat poison to you. This works well for those people who say, "Come on, a little won't kill you…". Ask the person how they would feel if you offered them 'just a little' rat poison. Would they take it? After all, it's just a little.

You get my point. I've been doing this for more than twenty years and patients report that this example does seem to communicate well to others. Feel free to utilize whatever talking points work best for you, but PLEASE, don't let peer pressure damage your good health.

9. Some people have close relatives they know to have celiac disease or other autoimmune diseases and they don't get tested for gluten intolerance because they're 'afraid to find out' or they don't feel too badly or they just don't know about the strong correlation between gluten intolerance and autoimmune disease.

Discussion: There's a saying that goes, "What you don't know can't hurt you." Unfortunately that's not true for people with gluten intolerance. Deciding not to get tested doesn't diminish or slow down gluten's degenerative effects.

Gluten isn't something you can hide from. If gluten intolerance or autoimmune diseases are a part of your family tree I would strongly suggest that you get tested for both celiac disease and gluten sensitivity and if negative, confirm the accuracy or inaccuracy of that test result with a thirty day gluten elimination diet.

It is that important that you know for sure that you are not part of the genetic predisposition that is present in your family tree.

10. Patients eliminate gluten due to a diagnosis of gluten intolerance but after initially feeling much better, they begin to feel poorly again and don't know what to do to correct the problem.

Discussion: This may be the last point on our list but it certainly is not the least important. In fact, when I'm talking with individuals who know they have celiac disease or gluten sensitivity, this is one of the most common complaints I hear.

Unfortunately the medical profession's sole treatment strategy for celiac disease is gluten avoidance, period. I wish that was enough, but for the vast majority of people it isn't.

The secondary effects created by gluten intolerance do not remedy themselves when gluten is removed from the diet. Gluten has a devastating effect on the body's immune system and in order to normalize that immune system there are several factors that must be addressed, the most common of which follow:

a. The presence of pathogenic (disease-causing) organisms. These can be bacteria, parasites, amoeba, etc., but they must be discovered and treated in order to remove excess stress from the immune system and to allow vital healing of the small intestine.

b. An imbalance of the good bacteria or probiotic population in the small intestine. These probiotics (or microbiome) account for the strength of the immune system and supporting their restoration to a healthy, robust level is critical for the immune system as well as the prevention of disease.

c. Cross-reactive foods can be part of the patient's diet and these foods can mimic the effects of gluten thereby preventing healing and causing gluten-related symptoms despite a gluten-free diet. These foods are often temporary irritants while the body is healing but we have found some patients who require permanent elimination of some of these foods.

d. Hormonal imbalance created by the stress on the body that gluten creates is something that must be normalized through natural means in order to regain mental balance, increased energy levels and normalized weight, just to name a few.

e. Toxic elements including heavy metals and poor detoxification abilities of the body are also a potential hurdle that needs to be overcome when restoring health to someone who is gluten intolerant.

f. Enzyme and vitamin deficiencies should be evaluated and treated as they are discovered.

Basically, the stress on the system that gluten has created must be diagnosed and remedied in order for the individual to regain optimal health.

Addressing these secondary effects is not complicated. It takes the knowledge of what they are, how to correctly test for them and how to effectively treat them, but this is not difficult. The lack of widespread awareness of these factors results in many individuals continuing to suffer despite maintaining their gluten-free lifestyle.

This just isn't fair and it's something I am passionate about remedying. I hope you found this helpful for yourself, a family member or a close friend. Feel free to contact me if you need assistance. I'm here to help and welcome you to give me a call for a free health analysis. Call 408-733-0400.

Celiac.com 02/16/2018 - Gluten sensitivity is a real thing. None other than Alessio Fasano, the renowned celiac researcher at the University of Maryland, has said as much. The problem is, there is not really an accurate way to diagnose it. But now that gluten-free foods are Big Business, generating almost $2.5 billion in US sales in 2010, Fasano and fourteen other experts convened in London to characterize exactly who needs to avoid gluten and why. Results are reported in BMC Medicine and covered by the Wall Street Journal.

Wheat allergies can be diagnosed with a skin prick showing the presence of IgE antibodies. These are not particularly accurate, however, because the reagents used do not necessarily contain all of the allergens present in wheat and because they give a positive result for people who are allergic to grass pollens. Thus, an oral food challenge is often required for a definitive diagnosis.

Unlike the wheat allergy, celiac disease, dermatitis herpetiformis, and gluten ataxia are autoimmune diseases. They are mediated by the IgA class of antibodies that are induced by the presence of gluten to attack the body's own transglutaminase enzymes at different locations; in celiac disease they attack tissue transglutaminase in the gut, in dermatitis herpetiformis they attack epidermal transglutaminase in the skin, and in gluten ataxia they attack tTG6, a transglutaminase expressed in the brain. In contrast to an allergy these ailments cannot be outgrown, and those who have them must strictly avoid gluten, and the related proteins in barley and rye, for their entire lives.

People with gluten sensitivity are defined as those have neither an allergic nor an autoimmune response to gluten, but who feel crappy when they eat it and better when they avoid it. There is suggestive evidence that gluten sensitivity might be mediated by the innate immune system, a more primal arm of the immune system than the adaptive immune system that mediates celiac disease. Eating gluten can often make these people feel sicker than it does people with celiac disease, who can be asymptomatic; yet gluten does not destroy their intestines, whereas even the tiniest drop of gluten can cause damage to the intestines of celiac patients.

Fasano notes that all adverse reactions to gluten are on the rise. Perhaps this is because the wheat variety that is now most common has a much higher gluten content than those varieties that have been used historically, and because gluten is now a hidden ingredient in many processed foods—so we are consuming more of it than we ever have before. However, he also knows a trend when he sees one, noting that "a placebo effect of the dietary treatment is often difficult to determine" and "the market is filled by individuals affected by maladies that have been claimed to be affected by gluten exposure, including autism spectrum disorder, attention deficit hyperactivity disorder, multiple sclerosis and irritable bowel syndrome, but for which there is no evidence of the effectiveness of this diet."

Sources:

• Sapone et al. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Medicine 2012, 10: 13.
• http://online.wsj.com/article/SB10001424052970204136404577206891526292590.html?KEYWORDS=gluten+free 
• http://blogs.wsj.com/health/2012/02/07/health-journal-deciphering-the-ailments-tied-to-gluten/?KEYWORDS=gluten+free 

Celiac.com 02/02/2018 - An opinion article by Dr. Di Sabatino and Dr. Corazza in the February 2012 issue of Annals of Internal Medicine (1) has unleashed a storm of opinion articles in the popular media that decry the gluten-free diet. The article by these two physicians is mostly reasonable and thoughtful but there are a couple of problems with it. The authors devalue patients' participation in their own health care and implicitly assert that gluten is a healthy food for most people. They do so through a protocol they have devised and by stating that they wish to prevent "a gluten preoccupation from evolving into the conviction that gluten is toxic for most of the population" (1). This statement, and the media claims that followed, reflect several deeply flawed assumptions and perspectives that are not only unscientific, they elevate the physician's observations over the individual's insights into her/his own health.

The first assumption, of course, is that gluten is a healthy food for all those without celiac disease. Yet in the very same article, Di Sabatino and Corazza offer a list of afflictions that, in the absence of celiac disease, improve or completely disappear when gluten is withdrawn. Thus, while they acknowledge the existence of these illnesses, they simultaneously assert that a condition of gluten preoccupation exists and that gluten is not toxic for most of the population. They go on to bemoan the absence of clear diagnostic criteria for these non-celiac, gluten-induced illnesses, calling for an individualized approach to diagnosis that would involve patients following a single-blinded gluten challenge test for subjective symptoms and an open test for objective signs and symptoms.

In a nutshell, they want patients to undergo a gluten challenge, without knowing (the patient is the one who is blinded) when they are or are not gluten-free, to confirm, for the physician, the patient's claim that her/his symptoms are legitimately linked to gluten ingestion. The gluten challenge is for the sole benefit of the physician. If she/he observes that the signs and/or symptoms worsen with gluten exposure and/or improve after excluding gluten then the physician will be reassured that the patient's self-report is accurate. Does that strike anyone else as a trifle offensive?

Of course, this assumes that the physician's tests and observations are somehow more valid than the patient's complaints. I don't want to be too cranky about this. After all, I'm a pretty skeptical person and I think it is important to resist random claims, especially about dietary restrictions, without supporting evidence. But honestly, when an individual is seeking medical advice and reports on their signs and symptoms, there seems little cause to doubt that patient's word. After all, if they misrepresent the facts they are only hurting themselves. Patients can, of course, be mistaken. And those who are interested in a physician's diagnosis might want to subject themselves to such a paternalistic gluten challenge. I have no quarrel with patients making that informed choice. Perhaps some patients will have conditions imposed by their insurance company. Or maybe they will have some other reason to accept this protocol. However, it should not be overlooked that, at its root, this protocol is the antithesis of encouraging patients to take responsibility for their own health care.

Further, despite their implied disdain for patients, Doctors Di Sabatino and Corazza don't seem to have considered some of the risks involved in their newly hatched diagnostic protocol which is aimed at pushing back against what they seem to believe is a growing idea that "gluten is toxic for most of the population". In brief, they advocate patients resuming gluten consumption, thus incurring several serious risks to the health and welfare of the patient so physicians may stem the growing tide of gluten-free patients who have undertaken the diet without the blessing of a gastroenterologist or physician.

Please take a moment to consider this proposition. The gluten-free diet is restrictive, inconvenient, and expensive. Why would anyone choose to follow such a diet without being convinced that it was valuable to them? Di Sabatino and Corazzo freely acknowledge that there is a dearth of diagnostic tests and protocols for diagnosing or excluding non-celiac gluten sensitivity (although they do overlook some basic tests that I'll discuss shortly).

The inconvenience of a gluten-free diet should disabuse critics and skeptics of much of their doubt. However, even if this huge factor is ignored, there are issues of opioid addiction, appetite manipulation, and the risks of triggering allergies, chronic inflammation, autoimmune disease, and psychiatric illness, any or all of which can accompany ingestion of gluten in some individuals. All of these costs and risks are ignored by these two innovators in their Brave New World of non-celiac gluten sensitivity.

Addiction to Gluten-derived Opioids
Most of the people I know who follow a gluten-free diet are well aware of how addictive gluten can be. Once a person has broken away from an addictive substance, it seems very questionable, to say the least, to persuade them, ostensibly in the interests of their health, to ingest that addictive substance again. Since 1979, we have had solid evidence of the morphine-like peptides of gluten grains (2). Many subsequent reports have replicated the findings first reported by Christine Zioudrou and her colleagues (3, 4, 5, 6) so there is little cause to question the addictive potential of gluten grains and the foods derived from them. How wise would it be to ask a former smoker to do a trial of smoking cigarettes for a few weeks? Or to ask an alcoholic to return to alcohol to reassure his physician of the correctness of the patient's choice to quit?

Appetite Manipulation
Relatedly, an opioid blocker, Naloxone, was given to a group of binge eaters who experienced reduced "duration and magnitude of binge eating episodes" (7). Another group, of healthy volunteers, showed 28% reductions in food intake on days when they were given the same opioid blocker (8). Although gluten opioids were not the intended target of the Naloxone, it may be that this was exactly what this drug was doing in both of these studies. As the obesity epidemic spreads, it is increasingly important to exercise care with respect to foods that cause abnormal and unwarranted increases in appetite. Other researchers have also reported reductions in food intake after administration of opioid blocking medications (9, 10).

Autoimmunity
Although obesity is an important health concern, autoimmune disease may be of at least equal concern. The loss of integrity of the mucosal barrier of the small intestine is now considered an important factor in the development of many cases of autoimmunity (11, 12). This group of ailments currently plagues the western world with their serious, sometimes lethal consequences. Especially among those who report symptoms in association with gluten consumption, it seems only prudent to proceed with an abundance of caution. When there may be an increased risk of developing one or more autoimmune diseases, a return to gluten consumption seems a very poor choice.

In susceptible individuals, gluten consumption triggers zonulin production. Zonulin mediates the tight junctions between the epithelial cells that form the protective barrier between the digesting food in our intestines, and our bloodstreams (11). Thus, ingesting gluten , for those at risk, invites leakage of undigested and partly digested proteins into the bloodstream. The immune system sees these foreign substances as invaders and attacks them in the same manner it would attack a viral or bacterial invader. These same antibodies sometimes attack self tissues with similar protein structures. Because gluten is ingested each day, several times a day, this leaky gut and flood of antibodies can quickly become chronic. Why would a caring health-care professional advise someone who is reporting symptoms associated with gluten consumption to return to eating this substance when the patient may well be reporting early signs and symptoms of a developing autoimmune disease?

Allergies and Inflammation
Similarly, a compromised intestinal mucosa has been connected to allergies and chronic inflammation. It seems irresponsible to bring one's professional authority to bear on the patient, encouraging them to return to eating gluten so the physician may be persuaded that the patient is accurately reporting their responses to gluten.

At the Department of Neurology at the Royal Hallamshire Hospital in Sheffield, U.K., a group of researchers have been reporting, since the mid 1990s, the identification of elevated serum IgG antibodies against one of the proteins in gluten among a majority of patients with a variety of neurological diseases of unknown origins (13). They also report that the prognosis is quite poor for these people. I attended a presentation by the lead researcher of this group, Dr. Marios Hadjivassiliou, in 2005. He repeatedly stated that these individuals require an exceedingly strict gluten-free diet to have any chance of improving their prognosis. Yet doctors Di Sabatino and Corazza's approach would further compromise these patients' chances of recovery to satisfy the doubts held by physicians.

The research group at the Royal Hallamshire Hospital, and many other researchers, continue to use testing for IgG and IgA class antibodies against gliadin, a sub-group of gluten proteins, as an indicator of gluten sensitivity (13). It may be imperfect, but any time a particular food protein is triggering an abnormal immune response in our bodies, it seems reasonable to assert that this individual is sensitive to that food protein. When celiac disease has been ruled out, positive IgG and/or IgA anti-gliadin antibodies clearly indicate a condition of non-celiac gluten sensitivity. There are other forms of non-celiac gluten sensitivity that may be missed by these tests, but it is clear that IgG and IgA testing for anti-gliadin antibodies is identifying some, perhaps most, cases of non-celiac gluten sensitivity. About 12% of the general population shows elevated levels of IgG antibodies against gluten (13, 14). Notwithstanding Di Sabatino and Corazza's assertion that there are no tests for non-celiac gluten sensitivity, IgG and IgA anti-gliadin antibody tests are certainly one means of identifying gluten sensitivity, whether in the blood or in fecal matter. Additional markers may well arise from current and future research.

Psychiatric Illnesses
Some forty years ago, Dr. Curtis Dohan and his colleagues established a clear connection between gluten and dairy proteins and schizophrenia (15). Doctors Singh and Kay replicated those findings (16). The issue was hotly debated on the basis of several other studies of sloppy design that followed. For a long time, the connection with gluten was dismissed because of the contradictory reports in the medical literature.

In the last fifteen years, another spate of research has emerged showing that Dr. Dohan, Dr. Singh, and both of their research groups had unearthed a compelling connection with serious implications for the effective treatment of a sub-group of patients with schizophrenia and other mental illnesses. Some of these findings were capricious, as in the case of a long-term schizophrenic who was placed on a ketogenic diet. After 53 years of battling her symptoms she experienced complete relief from her schizophrenia (17). Genetic studies and investigations of schizophrenic patients and bi-polar patients have also shown that gluten may be an important factor in these conditions (18, 19, 20, 21, 22, 23, 24, 25 ) which are both common and debilitating. A subset of autistic patients have also experienced symptom improvement on a gluten-free diet (25, 26, 27).

Thus, there is compelling evidence across a number of specialty areas of human illness in which gluten plays a role as an important contributor to symptoms and/or it lies at the root of these conditions. I must therefore question how Dr. Di Sabatino and Dr. Corazza can assert that gluten is not toxic to most people? Their implicit claim to that effect is questionable given the wide range illnesses that it contributes to or causes. We now know that increased production of zonulin, the mediator of intestinal barrier integrity, discovered at the University of Maryland in 2000 (28), is triggered, in some people, by gluten ingestion (29). Subsequent research has revealed that zonulin is the precursor of haptoglobin 2 which is found in about 80% of the human population (11). In the absence of further research, there may well be cause to suspect that gluten grains are a healthy food for only about 20% of the population. So these two physicians would have us continue to consume gluten until such time as we develop full-blown illness or signs and symptoms acceptable to our physicians. Surely that has put the cart before the horse. Their patients do not visit them for the sole benefit of the physician. Nonetheless that is the central thrust of this protocol.

This published opinion has spawned a number of articles online and in the popular press, all of which (that I've seen) seem to ignore all of the concessions to non-celiac gluten sensitivity mentioned in the article by doctors Di Sabatino and Corazza . Some of these spin-off commentaries even use the original article to support their suggestions that a gluten-free diet is inappropriate even for those with symptoms that are relieved by the diet. This blatantly contravenes the opinions expressed by Di Sabatino and Corazza but these journalists don't let the facts get in the way of their over-simplified, august opinions. While I take exception to their implied distrust of patients, at least Di Sabatino and Corazza concede that the gluten-free diet is appropriate for those who experience symptom mitigation or remission when avoiding gluten. These reporters make no such concession.

One article from the LA Times, states: "That hasn't stopped many people from declaring they are gluten sensitive, even though they may not be" (30). This journalist seems to imagine that he/she is in a better position to judge whether there is benefit in a gluten-free diet than the people who choose to follow it. Given Di Sabatino and Corazza's flagrant disrespect for patients, I suppose similar disparagement by the journalists who mindlessly follow should not surprise us. They, too, dispense medical advice that could prove very harmful. The quality of that advice is about what one might expect under the circumstances.

Doctors Di Sabatino and Corazza not only acknowledge non-celiac gluten sensitivity as a cause for symptoms very similar to those of celiac disease, they call for further research to develop and codify diagnostic protocols that will help clinicians better recognize and treat this newly recognized ailment. They go on to acknowledge that conditions including "headache, lethargy, attention-deficit/hyperactivity disorder, ataxia, or recurrent oral ulceration" in the absence of celiac disease often improve or resolve on a gluten-free diet. Their unfortunate denial of gluten as toxic seems to have invited much of the spin-off, journalistic conjecture under such titles as "Gluten-free diets not always necessary, study suggests" (31). Even the characterization of this opinion article as a study is misleading in the extreme.

These journalists and medical opinion authors also seem oblivious to the strong connection between learning disabilities and gluten consumption (32, 33). My own professional experience echoes Blair's report in which 70% to 90% of children with dyslexia accelerated their reading and writing skills more rapidly than mainstream children not afflicted with dyslexia during a six month trial of the gluten-free diet (33). This is startling! In most cases, children with dyslexia work very hard to reduce the gap by which they are falling behind in their studies.

In my work it is often difficult to persuade parents of a child who struggles with learning disabilities to undertake a six month trial of a gluten-free diet. Yet the positive results are often quite astounding. The medical opinion expressed by Di Sabatino and Corazza and the subsequent spin-off in the popular press have just made this task substantially more difficult. Who wants to be characterized as a radical nut case? Who wants to risk their child's learning and welfare on a fad diet? These are the accusations implicit in the Di Sabatino and Corazza characterization of "gluten preoccupation" and the journalistic frenzy that followed. One article in The Toronto Star claims that the gluten-free diet is dangerous. Anyone who has followed it knows that claim to be pure nonsense. The article is based on an interview with Dr. Corazza so it is difficult to tell whether the journalist got it wrong or Dr. Corazza actually made this silly claim. The dangers that Dr. Corazza is quoted about are that it will be more difficult to get a diagnosis of celiac disease and that the diet will cost more money (34). Yet the title says " Gluten-free diets could be dangerous, doctors say" (34).

What these journalists and physicians missed is the rapidly growing body of evidence showing that increasing numbers of ailments among escalating numbers of people are driven by this ubiquitous food (2-35) . Gluten may or may not be toxic for most of the population. We don't know. We can't know that without more research. Neither can Di Sabatino and Corazza or any of the journalistic lemmings who leaped off that same cliff, asserting that those who take up a gluten-free lifestyle are the ones who are misguided. Regardless of whether gluten is toxic to most of us, a gluten-free diet certainly is not. Just how do Dr. Corazza and/or these journalists imagine that humans survived and thrived before gluten grains were first cultivated about 10,000 years ago? And most of the world's populations survived and thrived without gluten for many more millennia without gluten grains.

The growing numbers of people who are willing to accept the inconvenience and expense of a gluten-free diet because of the benefits they experience should incite curiosity and discourse - not contempt and dismissal. Gluten may be toxic to many more people than are currently identifiable by limited available testing. Asserting one side or the other of this argument is at least premature. At most it could prove very harmful to those individuals who listen and obey the voices of experts and journalistic hucksters using devious methods to promote their own pet ideas.

Sources:
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4. Fukudome S, Yoshikawa M. Gluten exorphin C. A novel opioid peptide derived
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6. Huebner FR, Lieberman KW, Rubino RP, Wall JS. Demonstration of high opioid-like activity in isolated peptides from wheat gluten hydrolysates. Peptides. 1984 Nov-Dec;5(6):1139-47.
7. Drewnowski A, Krahn DD, Demitrack MA, Nairn K, Gosnell BA. Naloxone, an opiate blocker, reduces the consumption of sweet high-fat foods in obese and lean female binge eaters. Am J Clin Nutr. 1995 Jun;61(6):1206-12.
8. Cohen MR, Cohen RM, Pickar D, Murphy DL. Naloxone reduces food intake in humans. Psychosom Med. 1985 Mar-Apr;47(2):132-8.
9. Wolkowitz OM, Doran AR, Cohen MR, Cohen RM, Wise TN, Pickar D. Single-dose naloxone acutely reduces eating in obese humans: behavioral and biochemical effects. Biol Psychiatry. 1988 Aug;24(4):483-7.
10. Trenchard E, Silverstone T. Naloxone reduces the food intake of normal human volunteers. Appetite. 1983 Mar;4(1):43-50.
11. Tripathi A, Lammers KM, Goldblum S, Shea-Donohue T, Netzel-Arnett S, Buzza MS,Antalis TM, Vogel SN, Zhao A, Yang S, Arrietta MC, Meddings JB, Fasano A. Identification of human zonulin, a physiological modulator of tight junctions, as prehaptoglobin-2. Proc Natl Acad Sci U S A. 2009 Sep 29;106(39):16799-804. Epub 2009 Sep 15.
12. Fasano A. Leaky gut and autoimmune diseases. Clin Rev Allergy Immunol. 2012 Feb;42(1):71-8.
13. Hadjivassiliou M, Gibson A, Davies-Jones GA, Lobo AJ, Stephenson TJ, Milford-Ward A. Does cryptic gluten sensitivity play a part in neurological illness? Lancet. 1996 Feb 10;347(8998):369-71.
14. Fine K. Enterolabs. Private communication.
15. Dohan FC, Grasberger JC, Lowell FM, Johnston HT Jr, Arbegast AW. Relapsed schizophrenics: more rapid improvement on a milk- and cereal-free diet. Br J Psychiatry. 1969 May;115(522):595-6.
16. Singh MM, Kay SR. Wheat gluten as a pathogenic factor in schizophrenia. Science. 1976 Jan 30;191(4225):401-2.
17. Kraft BD, Westman EC. Schizophrenia, gluten, and low-carbohydrate, ketogenic diets: a case report and review of the literature. Nutr Metab (Lond). 2009 Feb 26;6:10.
18. Dickerson F, Stallings C, Origoni A, Vaughan C, Khushalani S, Leister F, Yang S, Krivogorsky B, Alaedini A, Yolken R. Markers of gluten sensitivity and celiac disease in recent-onset psychosis and multi-episode schizophrenia. Biol Psychiatry. 2010 Jul 1;68(1):100-4. Epub 2010 May 14.
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Celiac.com 04/16/2014 - I am writing this because I just attended my first brown bag lunch session at Palomar Medical Center  (PMC) and was nearly black balled for my audacity to speak out against what the lecturing registered dietitian said when she made the statement “ a gluten-free diet (GFD) is a fad diet that will cause harm by depriving the body of needed vitamins and minerals” and that “no one should follow this diet unless they have been formally diagnosed with celiac disease”.  I want to demonstrate that a GFD is not harmful in any way and that it may be a superior diet for many people, even those who have not been “diagnosed” with celiac disease.

I was attending the lecture because I have been dismayed by the nutritional information being sent to employees via e-mail at PMC. I am passionate about health and nutrition and thought that by attending I would be able to voice my opinions and create a dialog so everyone would become more knowledgeable about food and  possibly improve the quality and content of future information about nutrition.  What I got was not what I expected. My opinions were not wanted and I was immediately told that the 30 minute lecture did not allow time for my questions and objections. I have a Bachelor of Science in nursing and it was the first time in my life I have ever felt like the “teacher” was the only authority on the subject and there was no room for discussion.  Two women from the front of Grey Bill auditorium told me in no uncertain terms to shut up and that I would be dealt with later.     

The topic March 30, 2011 was on “Fad Diets” and though she did not discuss any fad diets in depth, the registered dietitian did, at the outset, make the statement as outlined above.  I immediately pointed out that there are many whole grain products someone on a GFD may consume which would provide nutrients similar to those found in wheat.  But the speaker insisted that people fallowing a GFD would likely not know about other grains and thus would be lacking B-complex vitamins and minerals such as zinc, iron and copper.

A gluten-free diet in no way short changes you of these vital nutrients and it should not be assumed this hospital’s employees are too ignorant to be aware of the various gluten-free grains that are available. Certainly, inaccurate information should not be presented in  an arena where people are gathering to learn about their health and where that misinformation may be passed on to patients  and their families.  I have heard that registered dietitians and the food industry are a little too closely linked and now I  have now experienced it first hand.

The food industry has, for years, been altering the foods we eat to make them look or taste better. They have been changing textures and adding colors with their armory of food additives.  Now, however, there is mounting evidence that this manipulation of food and it’s over abundance in the standard American diet (commonly labeled SAD ) has taken its toll on our health.  Food industries are out to make a profit, but do we have to help them by misleading our employees about food?  Gluten is, after all, not only present in grain products where you would expect it, as the primary protein in wheat, but in nearly all processed foods contain gluten - otherwise known as vegetable protein, hydrolyzed vegetable protein, hydrolyzed plant protein, malt, malt flavorings and  vegetable gum (to name just a few of its many aliases).  Gluten is used in seasonings, condiments, processed meats, commercial soups, broths, ice cream  and nearly all packaged foods found at your typical super-market.  Thus, giving up gluten is giving up highly processed foods. In other words, a gluten-free diet is based primarily on whole foods.  Furthermore, gluten-free grains such as amaranth, quinoa and wild rice, among many others, are  far superior to wheat in their vitamin and mineral content. Hence my inability to sit quietly and listen to the misinformation that was being presented.

Finally, I tried to point out that getting a celiac diagnosis from a western trained  physician is not easy.  There are far too many ailments that, while caused by gluten intolerance , are diagnosed as a host of other illnesses.  So many conditions, in fact, that it would be impractical to list them all, but here are just a few: colitis, irritable bowel syndrome, constipation, diarrhea, flatulence, mouth ulcers, abdominal pain, anemia, ataxia, epilepsy, fatigue, depression, arthritis, autism, autoimmune disorders, ear infections, eczema, headaches, heartburn, irritability, neurological disorders, psychiatric disorders, hypoglycemia, diabetes, migraines, osteoporosis, sinus problems.... the list goes on and on. What doctor is going to order an intestinal biopsy when you are reporting symptoms of depression?

It usually takes between seven and ten years of suffering with a multitude of symptoms before a diagnosis of celiac disease is made and it is estimated that 1% of the population suffers from celiac disease but most remain undiagnosed. Therefore, it would be wise to remove gluten from your diet if you are experiencing unexplained symptoms and you wish to find a cure instead of simply covering up the symptoms with the various pharmaceuticals western trained physicians will prescribe for you.  Even if celiac disease is not the cause, you may benefit from the healthier lifestyle offered by a whole foods diet free of artificial food additives.

Celiac.com 04/09/2014 - The human gastrointestinal tract contains approximately 1014 bacterial cells that form a unique, diverse and very dynamic microbial ecosystem also known as gut microbiota. The genomes of all intestinal microbes form the “microbiome”, representing more than 100 times the human genome. The composition of gut microbiota is crucial for human health. Normal gut microbiota enhances digestive processes, produces certain vitamins and nutrients, facilitates absorptive processes, participates in development and maturation of the immune system and limits colonization of the gut by pathogenic microorganisms. It has been demonstrated that the following predominant microorganisms constitute for the normal gut microbiota: Bacteroides, Clostridium, Eubacterium, Veillonella, Ruminococcus, Bifidobacterium, Fusobacterium, Lactobacillus, Peptostreptococcus and Peptococcus. Diet is a major environmental factor influencing gut microbiota diversity and functionality.

Abnormalities in the composition of normal gut microbiota, also known as dysbiosis, frequently result in the development of chronic inflammatory, autoimmune and atopic processes not only within the gut but also in the distant body compartments such as skin, exocrine glands, the brain, muscles and joints.

It is well recognized that people affected by poorly controlled celiac disease have detectable dysbiosis.

Compared to healthy individuals, people with active celiac disease are characterized by higher numbers of Gram-negative bacteria, known to activate pro-inflammatory processes, and lower numbers of Gram-positive bacteria benefiting the gastrointestinal tract and anti-inflammatory responses. Furthermore, recent studies of children with celiac disease showed that even a strict compliance with a gluten-free diet does not completely restore the normal gut microbiota. Di Cagno and colleagues analyzed the composition of gut microbiota in children with celiac disease on a strict gluten-free diet as compared to a group of matched, non-celiac controls. The study showed that the levels of Lactobacillus, Enterococcus and Bifidobacteria were significantly higher in fecal samples from healthy children rather than from celiac children. On the contrary, cell counts of potentially pathogenic microorganisms such as Bacteroides, Staphylococcus, Salmonella, Shighella and Klebsiella were significantly higher in celiac children compared to healthy children.

Based on the aforementioned data, it is obvious to propose that probiotics, defined as viable microorganisms benefiting gastrointestinal health, may serve as a valuable addition to the maintenance protocols for those with celiac disease.

Well established probiotic effects include:

• Beneficial effects on dysbiosis including control of yeast (Candida albicans) overgrowth
• Facilitation of pathogenic bacteria elimination (for example, Clostridium difficile and Helicobacter pylori)
• Reduction of local and systemic inflammatory responses
• Prevention of autoimmune and allergic reactions
• Prevention and treatment of antibiotic-associated diarrhea
• Normalization of intestinal contractions and stool consistency
• Reduction of the concentration of cancer-promoting enzymes and metabolites in the gut
• Prevention of upper respiratory and urogenital infections
• Cholesterol-lowering activity
• Experimental data indicate that probiotics can benefit celiac disease.

Lindfors K. and colleagues showed that live probiotic, Bifidobacterium lactis, bacteria inhibit the toxic effects induced by wheat gliadin in intestinal epithelial cell culture.

Papista C. et al. demonstrated (in a mouse model) that probiotics can prevent intestinal damage of celiac disease.

The published data on the beneficial effects of probiotics in celiac patients is limited. Our clinical experience (Institute for Specialized Medicine – www.ifsmed.com) indicates that appropriately selected probiotics significantly reduce diarrhea and bloating in patients with gluten intolerance and celiac disease. Furthermore, we see positive reduction of gluten-associated joint and muscle pain, fatigue and brain fog as well as on gut colonization with yeast. Probiotics also normalize markers of inflammation (for example, C-reactive protein) and markers of mucosal immune responses (for example, fecal secretory immunoglobulin A – sIgA). Typically, the benefits of probiotics administration cannot be seen instantly. It takes at least 4-6 months to see measurable benefits.

The choice of probiotics is another difficult issue for an inexperienced consumer.

The following probiotic strains may benefit those with celiac disease and gluten intolerance:

a. Lactobacillus acidophilus is a species of Lactobacilli which occurs naturally in the human and animal gastrointestinal tract and in many dairy products. The L. acidophilus strain DDS-1 is one of the best characterized probiotic strains in the world. The medicinal properties of L. acidophilus DDS-1 include: production of lactic acid supporting good bacteria in the gut, production of B and K vitamins, prevention of colon cancer, prevention of ‘traveler’s diarrhea’, inhibition of gastric/duodenal ulcers caused by Helicobacter pylori, reduction of symptoms of eczema and atopic dermatitis, reduction of serum cholesterol level, fermentation of lactose and reduction of symptoms of lactose intolerance, and reduction of intestinal pain.

b. Lactobacillus plantarum is a Gram-positive bacterium naturally found in many fermented food products including sauerkraut, pickles, brined olives, Korean kimchi, sourdough, and other fermented plant material, and also some cheeses, fermented sausages, and stockfish. The medicinal properties of L. plantarum include: production of D- and L-isomers of lactic acid feeding beneficial gut bacteria, production of hydrogen peroxide killing pathogenic bacteria, production of enzymes (proteases) degrading soy protein and helping people with soy intolerance, synthesis of amino-acid L-lysine that promotes absorption of calcium and the building of muscle tissue, production of enzymes (proteases) digesting animal proteins such as gelatin and helping people with pancreatic insufficiency.

c. Lactobacillus casei is a species of Lactobacilli found in the human intestine and mouth. The medicinal properties of L. casei include: production of lactic acid assisting propagation of desirable bacteria in the gut, fermentation of lactose and helping people with lactose intolerance, fermentation of beans causing flatulence upon digestion.

d. Lactobacillus rhamnosus is a species of Lactobacilli found in yogurt and other dairy products. The medicinal properties of L. rhamnosus include: production of lactic acid supporting good bacteria in the gut, production of bacteriocins and hydrogen peroxide killing pathogenic bacteria, prevention of diarrhea of various nature, prevention of upper respiratory infections, reduction of symptoms of eczema and atopic dermatitis, affecting GABA neurotransmitting pathway and reducing symptoms of anxiety.

e. Lactobacillus salivarius is a species of Lactobacilli isolated from saliva. The medicinal properties of L. salivarius include: production of lactic acid supporting good bacteria in the gut, reduction of inflammatory processes causing colitis and inflammatory arthritis, prevention of colon cancer.

f. Bifidobacterium bifidus is a Gram-positive bacterium which is a ubiquitous inhabitant of the human gastrointestinal tract. B. bifidus are capable of fermenting various polysaccharides of animal and plant origin. The medicinal properties of B. bifidus include: production of hydrogen peroxide killing pathogenic bacteria, modulation of local immune responses, production of vitamins B, K and folic acid, prevention of colon cancer, bioconversion of a number of dietary compounds into bioactive molecules.

g. Bifidobacterium lactis is a Gram-positive bacterium which is found in the large intestines of humans. The medicinal properties of B. lactis include: production of hydrogen peroxide killing pathogenic bacteria, modulation of local immune responses, production of vitamins B, K and folic acid, prevention of colon cancer.

h. Lactococcus lactis is a Gram-positive bacterium used in the production of buttermilk and cheese.  The medicinal properties of L. lactis include: production of lactic acid supporting good bacteria in the gut, prevention of colon cancer, fermentation of lactose and reduction of symptoms of lactose intolerance.

i. Saccharomyces boulardii is a probiotic strain of yeast first isolated from lychee and mangosteen fruit. Upon consumption, S. boulardii remains within the gastrointestinal lumen, and maintains and restores the natural flora in the large and small intestine.  There are numerous randomized, double-blind placebo-controlled studies showing the efficacy of S. boulardii in the treatment and prevention of various gastrointestinal disorders. Potential indications for use of Saccharomyces boulardii in humans include: 1) diarrhea/traveler’s diarrhea/antibiotic-associated diarrhea, 2) infection with Clostridium difficile/pseudomembranous colitis, 3) irritable bowel syndrome, 4) ulcerative colitis and Crohn’s disease, 5) partial IgA deficiency, 6)peptic-ulcer disease due to Helicobacter pylori. Published data also indicate that enzymes produced by S. boulardii can digest alpha-gliadin and related molecules.

j. Bacillus coagulans, also known as Lactobacillus sporogenes, is a gram-positive, spore-forming probiotic which is characterized by the increased survival in acidic gastric environment and in bile-acid-associated duodenal environment as compared to the commonly used probiotic microorganisms. Bacillus coagulans do not adhere to the human intestinal epithelium and is completely eliminated in four to five days unless chronic administration is maintained. Once in the intestines, Bacillus coagulans is activated and releases anti-inflammatory molecules or acts indirectly to eradicate organisms in the gut responsible for the inflammatory immune response. Activated Bacillus coagulans produces bacteriocins and lowers local pH by producing L(+) lactic acid that, along with competition for sites of mucosal adherence, works to dislodge and eliminate any antagonizing microbes that may be contributing to an inflammatory response. Bacillus coagulans also produces short-chain fatty acids such as butyric acid, a compound known to support the health and healing of cells in the small and large intestines and to contribute to modulation of the mucosal immune system.

To achieve therapeutic responses, the daily dose of the probiotics should be at least 25 billion CFUs (colony-forming units) and above. We recommend taking probiotics on an empty stomach either 20-30 minutes before breakfast or one-two hours after dinner with plenty of fluids. In those taking antibiotics, the time of the probiotic administration needs to be spaced out from that of antibiotics for at least several hours.

References:

• Papista C, Gerakopoulos V, Kourelis A, Sounidaki M, Kontana A, Berthelot L, Moura IC, Monteiro RC, Yiangou M.  Gluten induces coeliac-like disease in sensitised mice involving IgA, CD71 and transglutaminase 2 interactions that are prevented by probiotics. Lab Invest. 2012 Feb 13. doi: 10.1038/labinvest.2012.13.
• Sanz Y, De Pama G, Laparra M.  Unraveling the ties between celiac disease and intestinal microbiota. Int Rev Immunol. 2011 Aug;30(4):207-18.
• de Vrese M, Schrezenmeir J.  Probiotics, prebiotics, and synbiotics. Adv Biochem Eng Biotechnol. 2008;111:1-66.
• Lindfors K, Blomqvist T, Juuti-Uusitalo K, Stenman S, Venäläinen J, Mäki M, Kaukinen K.  Live probiotic Bifidobacterium lactis bacteria inhibit the toxic effects induced by wheat gliadin in epithelial cell culture. Clin Exp Immunol. 2008 Jun;152(3):552-8.
• Raffaella Di Cagno, Maria De Angelis, Ilaria De Pasquale, Maurice Ndagijimana, Pamela Vernocchi, Patrizia Ricciuti, Francesca Gagliardi, Luca Laghi, Carmine Crecchio, Maria Elisabetta Guerzoni, Marco Gobbetti, Ruggiero Francavilla.  Duodenal and faecal microbiota of celiac children: molecular, phenotype and metabolome characterization.  BMC Microbiology 2011, 11:219.