Gluten Sensitivity, Is Your Food Making You Sick? by Jeffrey Dach MD
Posted May 06 2011 1:50pm
Gluten Sensitivity, Is Your Food Making You Sick?
by Jeffrey Dach MD
Jim suffered from frequent migraines which were severe and incapacitating. After seeing a number of neurologists and trying multiple medications with no improvement, Jim finally came to see me. His last neurologist found he had a low vitamin D level, and started Jim on 10,000 units per day of vitamin D3. Jim reported that his psoriatic skin lesions were markedly better. However, his migraines were unchanged.
A connection between gluten sensitivity and psoriasis is well known. (18-20) In addition, I mentioned to Jim that food allergies can cause migraines (7), and gluten sensitivity can cause migraine headaches (8,9). In fact, gluten sensitivity is associated with all sorts of neurological disorders: cerebellar ataxia, epilepsy, myoclonic ataxia, chronic neuropathies, and dementia, mainly in middle-aged adults.(10-13) I suggested to Jim it was likely that a gluten free diet would be helpful in reducing his migraines.(8-9)
Gluten Testing with Entero-Labs
Jim's lifestyle made it difficult for him to go Gluten free, so I suggested he try the EnteroLabs gluten test . Sure enough, the test panel came back positive. Jim went on a gluten free diet, and 4 weeks later called me to report his migraines were much better. This article will discuss sensitivity to wheat gluten, a condition which is epidemic, yet mainly ignored or unknown by the medical system.(20)
Gluten is a protein is wheat products, such as bread, pasta, wheat cereals etc. About 1% or more of the population reacts to wheat gluten with an immune response and an inflammatory disorder of the small intestine which may cause malabsorption of key minerals, amino acids and vitamins. This has an inherited autoimmune component andgenetic testing is available.(17) Other diagnostic testing involves looking for the antibodies called TTG (transglutaminase) in stool or blood samples.
Immune Response In the Wall of the Small Bowel-Malabsorption
The immune response involves production of various antibodies and immune cells which damages the small intestine, reducing its absorptive ability. This is called malabsorption, and results in the inability to absorb key vitamins and minerals such as Iron, Calcium, folate and B12. These abnormalities will show up on the blood count as iron deficiency anemia, and B12/folate deficiency anemia.(22) gluten sensitivity, celiac disease may cause malabsorption of calcium, and the DEXA bone density scan may show osteoporosis (21).
Any Organ Can Be Involved
The auto-immune response can circulate freely through the body, crossreacting with other organ systems, unpredictably.
Immune Response in the Skinand Hair Follicles
Another common place for the immune response to attack is the skin, with a characteristic skin lesion called Dermatiformis Herpetiformis (it resembles Herpes) with intense burning, itching and blistering skin rash which is usually symmetrically distributed on the elbows, knees and the buttocks. The rash usually starts as small blisters that errupt into small erosions. Dermatologists will make the diagnosis of gluten sensitivity by doing a skin biopsy showing characteristic findings. Immunofluorescence of normal skin next to the vesicle typically shows granular IgA deposits in the upper dermis. (27-29) If the scalp is involved, this is called Alopecia Areata with patchy hair loss caused by auto-antibodies reacting with the hair follicles.(25-26)
If the immune response attacks the vascular system, there may be increased venous thrombo-embolism, stroke (2)(3), and coronary artery disease, etc. Thus, gluten sensitivity is one of the major causes of migraine headaches since it may cause inflammation of cerebral arteries, or the brain itself. (9)
If the immune response attacks the brain or spinal cord, this may cause a neurological disorder (4, 10-16) such as ataxia (5), uncoordination, peripheral neuropathy (tingling with pins and needles)(6).
Going to the Endocrinologist
The patient with gluten sensitivity may end up at the endocrinologist's office with issues such as: Type 1 diabetes mellitus, autoimmune thyroid disease, Addison disease, osteomalacia, secondary hyperparathyroidism, vitamin D or iron deficiency, fertility problems, hypogonadism in men, and autoimmune hypopituitarism.(23) Autioimmune thyroid disease is especially common among people with gluten sensitivity, with elevated anti-thyroid antibodies (Hashimotos) which decrease after initiating a gluten free diet.(24) One can make a case for gluten sensitivity testing for all patients with autoimmune thyroid disease (Hashimotos).
The gluten sensistive patient may have heart involvement with cardiomyopathy, a serious and potentially lethal form of heart failure. In addition, the gluten sensitive individual may have heart rhythm abnormaliies such as atrial fibrillation, reversible with a gluten free diet, if diagnosed early.Testing for gluten sensitivity should be done for such patients.(30-31)
A unusual lung disease of unknown etiology called Sarcoidosis is linked to gluten sensitivity. Sarcoidosis is thought to be an auto-immune disease because the treatment is immune suppression with prednisone. These patients may benefit from a gluten free diet.(34)
Addisons, Adrenal Failure
Complete failure of the adrenal glands to manufacture cortisol is called Addisons Disease and is associated with gluten sensitivity.(35) These patients may benefit from a gluten free diet.
Patients may go for decades with health problems, running through a succession of doctors, yet remain undiagnosed by the mainstream medical system. Treatment is usually curative with a Gluten Free Diet (GFD) which means avoiding all wheat products such as breads, pasta, wheat cereals, bakery goods etc.
Celiac disease is associated with a diversity of central nervous system manifestations although an association with stroke has not been documented. This case report describes a child who presented with a recurrent transient hemiplegia. Magnetic resonance imaging of the brain confirmed infarction; transcranial Doppler studies and magnetic resonance angiography were abnormal. Although there were virtually no gastrointestinal symptoms and the child was thriving, celiac disease serology was strongly positive and a duodenal biopsy confirmed the disease. Tissue transglutaminase is the major autoantigen in celiac disease and is thought to maintain vascular endothelial integrity. Antiendomysial immunoglobulin A antibodies, demonstrated to be the same autoantibody as antitransglutaminase, react with cerebral vasculature, suggesting an autoimmune mechanism for celiac disease associated vasculopathy. Because celiac disease is a potentially treatable cause of cerebral vasculopathy, serology-specifically antitissue transglutaminase antibodies-should be included in the evaluation for cryptogenic stroke in childhood, even in the absence of typical gut symptoms.
(3) http://www.ncbi.nlm.nih.gov/pubmed/19144365 Rev Neurol (Paris). 2009 Nov;165(11):962-6. Epub 2009 Jan 13. [Celiac disease and ischemic stroke].[Article in French] El Moutawakil B, Chourkani N, Sibai M, Moutaouakil F, Rafai M, Bourezgui M, Slassi I.
Neurological manifestations of celiac disease are various. An association with ischemic stroke is not common and has not been well documented. We report two cases. OBSERVATIONS: The first patient had experienced several transient ischemic strokes in the past 2 years and then had an acute ischemic stroke involving the territory of the right posterior cerebral artery. Investigations revealed celiac disease with no other recognizable etiology. The clinical course was marked by persistent visual aftereffects, but no new vascular event. The second patient had been followed since 1998 for celiac disease confirmed by pathology and serology tests. She was on a gluten-free diet. The patient had an ischemic stroke involving the territory of the left middle cerebral artery. Apart from a positive serology for celiac disease and iron deficiency anemia, the etiological work-up was negative.
DISCUSSION: The mechanisms of vascular involvement in celiac disease are controversial. The most widely incriminated factor is autoimmune central nervous system vasculitis, in which tissue transglutaminase, the main auto-antigen contributing to maintaining the integrity of endothelium tissue, plays a major role. Other mechanisms are still debated, mainly vitamin deficiency.
CONCLUSION: Being a potentially treatable cause of ischemic stroke, celiac disease must be considered as a potential etiology of stroke of unknown cause, particularly in young patients, and even without gastrointestinal manifestations.
Gluten and Neurological Disorder
(4) http://www.ncbi.nlm.nih.gov/pubmed/19845007 Mov Disord. 2009 Dec 15;24(16):2358-62. Neurological symptoms in patients with biopsy proven celiac disease. Bürk K, Farecki ML, Lamprecht G, Roth G, Decker P, Weller M, Rammensee HG, Oertel W.
(5) www.ncbi.nlm.nih.gov http: href?>www.ncbi.nlm.nih.gov/pubmed/12566288 Brain. 2003 Mar;126(Pt 3):685-91. Gluten ataxia in perspective: epidemiology, genetic susceptibility and clinical characteristics. Hadjivassiliou M, Grünewald R, Sharrack B, Sanders D, Lobo A, Williamson C, Woodroofe N, Wood N, Davies-Jones A. Gluten-sensitive enteropathy was found in 24%. HLA DQ2 was present in 72% of patients. Gluten ataxia is therefore the single most common cause of sporadic idiopathic ataxia.
Food allergies and migraine.Grant EC. Abstract 60 migraine patients completed elimination diets after a 5-day period of withdrawal from their normal diet. 52 (87%) of these patients had been using oral contraceptive steroids, tobacco, and/or ergotamine for an average of 3 years, 22 years, and 7.4 years respectively. The commonest foods causing reactions were wheat (78%), orange (65%), eggs (45%), tea and coffee (40% each), chocolate and milk (37%) each), beef (35%), and corn, cane sugar, and yeast (33% each). When an average of ten common foods were avoided there was a dramatic fall in the number of headaches per month, 85% of patients becoming headache-free. The 25% of patients with hypertension became normotensive. Chemicals in the home environment can make this testing difficult for outpatients. Both immunological and non-immunological mechanisms may play a part in the pathogenesis of migraine caused by food intolerance.
(16) http://ir.library.oregonstate.edu/xmlui/bitstream/handle/1957/17611/ Thesis%20Electronic%20Copy%20Dougher.pdf?sequence=1 http://ir.library.oregonstate.edu/xmlui/handle/1957/17611 Living Gluten-Free: An Analysis of Illness and Coping Narratives. Authors: Dougher, Carly E. Citation URL: http://hdl.handle.net/1957/17611 Abstract: Gluten intolerance is a condition that affects a significant portion of the world’s population. While awareness about the condition has recently increased, the condition remains poorly understood and therefore commonly mis- and underdiagnosed. In this paper, I examine the challenges in obtaining a gluten intolerant diagnosis and attempt to capture the experience of living gluten-free in a wheat-dependent society. Through interviews with gluten intolerant individuals in the Pacific Northwest, I expose a perceived lack of awareness and understanding about the condition in the western biomedical community that presented challenges for the participants pre-diagnosis, as well as a perceived lack of awareness and understanding about the condition in the general community that presented challenges for the participants post-diagnosis. Based on common themes extrapolated from these interviews, I argue that the western biomedical community as a whole lacks a complete understanding of the entire spectrum of gluten intolerance and that the information about gluten intolerance in published scientific literature does not match the lived experience.
(17) http://www.ncbi.nlm.nih.gov/pubmed/20947431 Trends Mol Med. 2010 Nov;16(11):537-50. Epub 2010 Oct 12. A genetic perspective on coeliac disease. Trynka G, Wijmenga C, van Heel DA. Coeliac disease is an inflammatory disorder of the small intestine with an autoimmune component and strong heritability. Genetic studies have confirmed strong association to HLA and identified 39 nonHLA risk genes, mostly immune-related. Over 50% of the disease-associated single nucleotide polymorphisms are correlated with gene expression. Most of the coeliac disease-associated regions are shared with other immune-related diseases, as well as with metabolic, haematological or neurological traits, or cancer. We review recent progress in the genetics of coeliac disease and describe the pathways these genes are in, the functional consequences of the associated markers on gene expression and the genes shared between coeliac disease and other traits.
CONCLUSIONS: The prevalence of celiac disease among osteoporotic individuals (3.4%) is much higher than that among nonosteoporotic individuals (0.2%). The prevalence of celiac disease in osteoporosis is high enough to justify a recommendation for serologic screening of all patients with osteoporosis for celiac disease.
Hematologic Manifestations of Celiac
(22) http://bloodjournal.hematologylibrary.org/content/109/2/412.full Hematologic manifestations of celiac disease . Thorvardur R. Halfdanarson1,, Mark R. Litzow1, and Joseph A. Murray2, Division of Hematology and 2 Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN Patients with celiac disease may present to hematologists for evaluation of various hematologic problems prior to receiving a diagnosis of celiac disease. Anemia secondary to malabsorption of iron, folic acid, and/or vitamin B12 is a common complication of celiac disease and many patients have anemia at the time of diagnosis. Celiac disease may also be associated with thrombocytosis, thrombocytopenia, leukopenia, venous thromboembolism, hyposplenism, and IgA deficiency.
OBJECTIVE: To review the association of celiac disease and various endocrine disorders and present the related clinical experience of a 3-physician adult endocrinology practice. METHODS: We provide an overview of the pertinent literature, discuss the clinical manifestations, genetics, and pathogenesis of celiac disease, and describe our clinical experience during a 5-year period.
RESULTS: Celiac disease has been associated with numerous disorders, including several conditions treated by endocrinologists-type 1 diabetes mellitus, autoimmune thyroid disease, Addison disease, osteomalacia, secondary hyperparathyroidism, vitamin D or iron deficiency, fertility problems, hypogonadism in men, and autoimmune hypopituitarism. After our clinical awareness was raised about these potential comorbidities, 18 patients were newly diagnosed with celiac disease in our clinical practice during a 5-year interval. All patients had been referred for endocrine evaluation or were undergoing follow-up for ongoing management of endocrine disorders. When a "celiac-associated" endocrine disorder coexists with other factors associated with celiac disease, we recommend performance of IgA class antibody testing, and either antiendomysial or anti-tissue transglutaminase antibodies provide high specificity and sensitivity for the diagnosis of celiac disease.
CONCLUSION: Endocrinologists have an opportunity to diagnose celiac disease, a relatively common disorder with profound clinical implications that can often be associated with various endocrinopathies.
Thyroid Disorders in Celiac patients
(24) http://www.ncbi.nlm.nih.gov/pubmed/11280546 Am J Gastroenterol. 2001 Mar;96(3):751-7. Prevalence of thyroid disorders in untreated adult celiac disease patients and effect of gluten withdrawal: an Italian multicenter study. Sategna-Guidetti C et al.
METHODS: A total of 241 consecutive untreated patients and 212 controls were enrolled. In 128 subjects a thorough assessment, including intestinal biopsy, was repeated within 1 yr of dietary treatment. Thyroid function was assayed by measuring the levels of TSH, free T3, free T4, thyroperoxidase, and thyroid microsome antibodies. RESULTS: Thyroid disease was 3-fold higher in patients than in controls (p < 0.0005). Hypothyroidism, diagnosed in 31 patients (12.9%) and nine controls (4.2%), was subclinical in 29 patients and of nonautoimmune origin in 21. There was no difference regarding hyperthyroidism, whereas autoimmune thyroid disease with euthyroidism was present in 39 patients (16.2%) and eight controls (3.8%). In most patients who strictly followed a 1-yr gluten withdrawal (as confirmed by intestinal mucosa recovery), there was a normalization of subclinical hypothyroidism. Twenty-five percent of patients with euthyroid autoimmune disease shifted toward either a subclinical hyperthyroidism or subclinical hypothyroidism; in these subjects, dietary compliance was poor. In addition, 5.5% of patients whose thyroid function was normal while untreated developed some degree of thyroid dysfunction 1 yr later.
CONCLUSIONS: The greater frequency of thyroid disease among celiac disease patients justifies a thyroid functional assessment. In distinct cases, gluten withdrawal may single-handedly reverse the abnormality.
(28) http://www.ncbi.nlm.nih.gov/pubmed/19344979 Rose C, Armbruster FP, Ruppert J, Igl BW, Zillikens D and Shimanovich I Autoantibodies against epidermal transglutaminase are a sensitive diagnostic marker in patients with dermatitis herpetiformis on a normal or gluten-free diet. J Am Acad Dermatol 2009; 61:39-43 Zone JJ Skin manifestations of celiac disease.
31 (28) http://www.mayoclinicproceedings.com/content/80/5/674.full.pdf Cardiomyopathy Associated With Celiac Disease . Mayo Clin Proc. 2005;80(5):674-676 CASE REPORT NISHEETH K. GOEL, MD; ROBERT D. MCBANE, MD; AND PATRICK S. KAMATH, MD . Celiac disease in adults is often asymptomatic or presents with extremely few symptoms. A high degree of clinical suspicion is required to make a prompt and correct diagnosis
Heart. 2007 September; 93(9): 1111–1115. Vascular disease in a population‐based cohort of individuals hospitalised with coeliac disease J F Ludvigsson, U de Faire, A Ekbom, and S M Montgomery
Results CD was associated with myocardial infarction (HR 1.27; 95% CI 1.09 to 1.48), angina pectoris (1.46; 1.25 to 1.70), heart failure (1.41; 1.22 to 1.62), brain haemorrhage (1.40; 1.05 to 1.88) and ischaemic stroke (1.35; 1.14 to 1.60). These risk estimates were similar when analyses were restricted to adults in whom vascular disease had been listed as the main diagnosis. In post‐hoc analyses, where reference individuals were restricted to inpatients, no association was found between CD and later vascular disease, except for a lower risk of heart failure (0.79; 0.68 to 0.92).
BACKGROUND AND AIM: Several case reports indicate a link between coeliac disease (CD) and sarcoidosis. Our main objective was to investigate the risk of subsequent sarcoidosis in individuals with CD in a general population cohort study. A second aim was to estimate the risk of CD in individuals with prior sarcoidosis. METHODS: We used Cox proportional hazards method to calculate the risk of subsequent sarcoidosis in 14,349 individuals who had received a diagnosis of CD (1964-2003) and 69,998 age- and sex-matched individuals without a diagnosis of CD. Subjects were identified through the Swedish national Inpatient Register. Conditional logistic regression was used to study the risk of CD associated with prior sarcoidosis.
RESULTS: CD was associated with an increased risk of sarcoidosis (Hazard ratio (HR) = 4.03; 95% CI = 2.32-7.00; p < 0.001), and was not notably affected by adjustment for socioeconomic index. In individuals with CD listed as the main diagnosis, the HR was 3.66 (95% CI HR = 1.80-7.45; p < 0.001). Prior sarcoidosis was associated with an increased risk of CD (Odds ratio = 3.58; 95% CI = 1.98-6.45; p < 0.001). CONCLUSION: Immune characteristics of CD may be linked to an increased risk of sarcoidosis.
(35) Celiac and Primary Adrenal insufficiency
(35) http://www.ncbi.nlm.nih.gov/pubmed/17595243 J Clin Endocrinol Metab. 2007 Sep;92(9):3595-8. Epub 2007 Jun 26. Risk of primary adrenal insufficiency in patients with celiac disease. Elfström P, Montgomery SM, Kämpe O, Ekbom A, Ludvigsson JF. Department of Pediatrics, Orebro University Hospital, SE-701 85 Orebro, Sweden.
OBJECTIVES: Earlier research has suggested a positive association between Addison's disease (AD) and celiac disease (CD). We have here investigated the risk of AD in individuals with CD from a general population cohort.
METHODS: Through the Swedish national registers we identified 14,366 individuals with a diagnosis of CD (1964-2003) and 70,095 reference individuals matched for age, sex, calendar year, and county of residence. We used Cox regression to estimate hazard ratios (HRs) for subsequent AD. Analyses were restricted to individuals with more than 1 yr of follow-up and without AD prior to study entry or within 1 yr after study entry. Conditional logistic regression estimated the odds ratio for CD in individuals with prior AD.
RESULTS: There was a statistically significantly positive association between CD and subsequent AD [HR = 11.4; 95% confidence interval (CI) = 4.4-29.6]. This risk increase was seen in both children and adults and did not change with adjustment for diabetes mellitus or socioeconomic status. When we restricted reference individuals to inpatients, the adjusted HR for AD was 4.6 (95% CI = 1.9-11.4). Individuals with prior AD were at increased risk of CD (odds ratio = 8.6; 95% CI = 3.4-21.8).
CONCLUSIONS: This study found a highly increased risk of AD in individuals with CD. This relationship was independent of temporal sequence. We therefore recommend that individuals with AD should be screened for CD. We also suggest an increased awareness of AD in individuals with CD.
There is a need for screening studies of patients with conditions associated with celiac disease to determine whether the large numbers of people with undiagnosed celiac disease currently are seeking health care.
http://findarticles.com/p/articles/mi_m0ISW/is_2002_Dec/ai_94538644/pg_2 Gluten intolerance: a paradigm of an epidemic. Townsend Letter for Doctors and Patients, Dec, 2002 by Stacy Astor Shaul . Other diagnostic tests which might be helpful in identifying gluten intolerance, is a urinary peptide for gliadorphin/caseomorphin test from The Great Plains Laboratory. This test measures the peptides from incompletely broken down pieces of protein from gluten and casein.
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