Many people who undertake the Paleo Diet often experience problems when introducing gluten back in to their diet despite not having noticed any issues prior to beginning the diet. There could be a host of reasons for this phenomenon. First, they may have had an issue before and never noticed. Many people see relief from multiple issues when beginning a Paleo Diet, perhaps gluten was the issue. Secondly, there could be a change to the microbiome that occurs with the diet. In this blog we will explore a few studies that could be evidence for this second reason.
While humans are unable to fully digest gluten because they lack the enzymes to do so, there are many strains of bacteria that colonize the GI tract that can. A recent study that looked at the microbiome of 22 human subjects found that 144 strains of bacteria found in the feces may participate in gluten metabolism(1). Some of the strains were able to metabolize gluten themselves while others made enzymes that could degrade gluten extracellularly, perhaps to break up the peptides for other symbionts.
The interesting part of this study is that a few of the strains were able to break down one of the more problematic peptides for people with celiac disease, the 33-mer. Obviously the more gluten you consume the more abundant these species would become holding everything else constant, so losing a few of these guys could be an issue. Going from a diet high in gluten to one very low in gluten and then testing the waters with a weekend gluten bomb may overwhelm your bugs' ability to breakdown gluten and, voila, problems.
Another study in 2010 found that microbes found within dental plaque and saliva produced enzymes that are capable of degrading gluten in vitro(2). These enzymes were capable of degrading 2 of the more problematic proteins found in gluten, the 33- and 26-mer. Interestingly, these bacteria can do so over a wide pH range meaning they could, in theory, work in regions of the digestive tract outside of the mouth. Even more interesting is that people who undertake a Paleo Diet tend to see an improvement in oral health which includes improvement in plaque deposits in the mouth. Could this lead to a decreased ability to metabolize gluten due to a drop in abundance of these gluten degrading microbes?
A follow up study by the same authors zeroed in on a couple of specific strains of microbes with powerful gluten degrading capabilities. These microbes had a powerful ability to break down both the 33- and 26-mer peptides with the remaining proteins not being able to initiate an immune response(3). One of these microbes was found to colonize both the oral cavity as well as the duodenum, meaning it may participate in gluten degradation in both the mouth and small intestine. While healthy subjects did have a higher percentage of this bacteria in the duodenum than people with celiac disease, the difference was not significant(6.5% vs 5.9%).
Looking at these studies, we can come to some conclusions. First off, while humans cannot digest gluten, there are microbes in the upper part of the human digestive tract that can. Second, there is the potential that initiating a gluten free diet for an extended period and then reintroducing large amounts of gluten all at once could become a problem if these microbes decrease in abundance and impact the host's ability to break down gluten. From these conclusions, it's safe to say that weekend gluten bombs are not a good idea for most people who go gluten free. If you intend to continue to eat gluten, you may want to keep a little in your diet from time to time to maintain a significant presence of the microbes that break it down since we are unable to. Finally, if you decide you are going to have gluten and haven't had it for a while, slowly introducing it may be a better approach than slamming down a 6 pack of brewskis and eating half of a pizza in a 3 hour period for the same reason.
Author's note: I personally limit my gluten exposure due to the potential effects on the microbiome. I'm not telling you whether or not you should eat gluten, I'm just giving advice on the appropriate ways to deal with reintroducing it if you have given it up for an extended period of time. Obviously this advice doesn't apply to people with celiac disease who, at this time, should never consume gluten.
Showing posts with label Gluten. Show all posts
Showing posts with label Gluten. Show all posts
Monday, July 14, 2014
Thursday, June 5, 2014
Gluten Freedom: Everything you wanted to know about gluten from the leading expert
I was recently looking for a new book to purchase when I came upon the book Gluten Freedom by Dr. Alessio Fasano. Dr. Fasano is considered the expert when it comes to Celiac disease, gluten sensitivity, and gluten research. I'm sure Cameron Diaz's new diet book will sell more copies which is kind of sad, but this book is not only solid on information, but it manages to do so while also being engaging. I have followed Dr. Fasano's work and thought this book would provide me with the most up to date information on gluten and how it affects human health since it was just published late last month. I wasn't wrong.
It's hard to come across a good reference book that is also easy to read on a topic as complex and scientific as this. For the most part they are loaded with jargon and provide scientific facts with little practical information. This book literally should be called Everything you Ever Wanted to Know About Gluten but Were Afraid to Ask. The book is broken up in to 4 parts and each part has quite a bit to offer.
The first part, called Gluten Enters the Picture, goes over the history of gluten: what it is, and why it's problematic. I don't want to give out a ton of the book since it's so good, but let's just say there are several reasons why most people should pay attention to gluten. He begins by discussing the three gluten related disorders: wheat allergy, gluten sensitivity, Celiac disease, and the way each condition causes problems. If you think this is primarily a genetic problem, think again. The gene variants that cause Celiac disease can be found in 30% of Caucasians and Celiac disease is literally exploding everywhere from Asia to Europe to all around the globe. Even so, you don't need these genetic variants to become sensitive to gluten and just because you have them doesn't mean that you will get Celiac disease. Despite the gene being so common in Caucasians, Celiac disease currently affects only 1% of them which points to the environment being as important in its development as having the gene variants. One of the more troubling aspects of this disease is that studies show that as many as 3,000,000 Americans likely have Celiac disease, but only around 200,000 have been diagnosed.
Even if you don't get Celiac disease, you can become sensitive to gluten. This is because no human has the enzymes necessary to break it down and it causes an immune response...in everybody. Now, this doesn't mean everyone should avoid gluten and Dr. Fasano states this emphatically. Many things we eat initiate an immune response, whether they become an issue is based on many things including age, health, and the microbiome. Given the history of Celiac disease, looking at blood samples from every decade shows that it doubles in occurrence every decade, it's becoming a growing problem heavily influenced by our environment. Dr. Fasano also discusses whether GMOs could be to blame(Unlikely), things that likely contribute to it, and even diagrams the specific components of gluten that are problematic for people and the responses they elicit.
Probably the most interesting part of this section was that while most people think of Celiac disease and other gluten related conditions as specific to the digestive tract, most people who get diagnosed with Celiac disease present with neurological symptoms, not digestive symptoms. Many people never even experience digestive disturbances making the disease a chameleon. There is a lot more to this section including leaky gut and zonulin, the brain, and autoimunity.
Part two is called Learning to Live Without Gluten and goes through most of the diet stuff: what to avoid, what you can eat, and provides a basic template for developing gluten free meals. Part 3 is called Gluten-Free Life and goes over many of the trappings of trying to live in society gluten free, discusses pregnancy and gluten, and provides a chronological guide to living gluten free. This is important because gluten related disorders, including Celiac disease, can strike people at any age with no history of issues with gluten containing foods in the past. This is a drastic change from the early days of research where it was considered a solely pediatric condition that wasn't even present in the US.
There are quite a few stories of people coming down with the disease and the years of misdiagnosis that most people experienced during the early stages of Celiac research. Despite many advances thanks to the research, many people still wait to get a proper diagnosis. There are also quite a few tips given by people who have learned to live a gluten free lifestyle the hard way: by being diagnosed at a time when no one knew what gluten was and when availability of gluten-free food was scarce at best.
Part four is one of the primary reasons I bought the book. It's called Going Beyond Gluten and covers what is currently going on in gluten research including the environmental factors at play(Aka the microbiome) and therapeutic interventions that could possibly lead to the previously unthinkable: worry free consumption of gluten by people with Celiac disease and gluten sensitivity. As Dr. Fasano points out in the book, throughout the history of gluten and Celiac disease research, many things that were once held as gospel were eventually overturned as the science clarified the picture. This includes existence of the disease in the US and Asian populations, it's prevalence, when it can afflict you, and how to successfully diagnosis the condition.
Overall this is an amazing book that clarifies quite a few things that I was uncertain about with regard to gluten. It thoroughly goes over the research on gluten to date and also gives a glimpse at what we can expect to see come out in the future. For someone with a gluten related disorder, it provides quite a bit of insight from people who have personal experience in dealing with a diagnosed gluten related disorder. It contains recipes as well as helpful tips in navigating society while going gluten free, whether you are doing it for yourself or your family. In addition, there are several resources in the back that provide help to people who may be having a difficult time going gluten free on their own. This book should be required reading for anyone with a gluten related condition as well as people who work with them who wants to know the science behind gluten as well as how to successfully live a gluten free life.
Gluten Freedom by Dr. Alessio Fasano
Thursday, May 22, 2014
Does gluten sensitivity exist?
Last week, articles took the internet ablaze questioning whether gluten sensitivity exists. Multiple articles written by multiple people claimed gluten sensitivity doesn't exist, including this one titled, Researchers who provided key evidence for gluten sensitivity have now thoroughly shown that it doesn't exist. These articles take a look at a study published last year that had some very interesting findings, they just didn't find that gluten sensitivity doesn't exist. In fact, it found the opposite, that it does exist. However, the study raises questions on those who see improvements in GI symptoms on a gluten free diet. Those findings are:
In the second part of the study, 22 subjects were given diets that increased FODMAP intake and included either gluten, whey, or no additional protein for 3 days and subjectively assessed for GI symptoms. All subjects received all 3 diets. This part of the study found that GI symptoms increased by similar levels in all groups with no specific response to gluten. However, there was an order effect which means that the order that a person received each diet had an effect on the results. In other words, people who received the diet with gluten first all had similar results to one another but different results than people who had whey or no gluten first.
So what does this study show? First off, this study supports the notion that NCGS exists, but that only a small number of people who respond positively to a gluten free diet are responding to lower gluten exposure. Instead, they may be responding to a reduction in FODMAP intake. But what does that mean?
First off, NCGS is poorly defined. To be diagnosed with NCGS you simply have to have symptoms of gluten sensitivity, not have celiac disease, and see an improvement in your symptoms with a gluten free diet. So anyone who has IBS or other GI problems who responds positively to removing gluten qualifies. There are 2 problems with this. The first problem is that a gluten free diet can mean many things. For some people it means removing grain-based foods, for others it means removing the gluten from grain-based foods.
If the culprit is specifically gluten, either one should work. The problem is, if it's not gluten and as this study suggests FODMAPS that are the problem for most people with GI symptoms, removing grain-based foods would be a successful approach while consuming grain-based foods with the gluten removed would have little effect since they would still contain FODMAPs. But why are FODMAPs a problem? The answer potentially lies in something called small intestinal bacterial overgrowth, or SIBO.
SIBO is a condition where bacteria overgrow in to the small intestine. While the large intestine houses a large number of bacteria, the small intestine houses far fewer in comparison. When an excessive amount of this bacteria begins to take up residence in the small intestine, people experience the same IBS symptoms associated with NCGS. In fact, some studies put the number of people with IBS who also have SIBO at approximately 80%(1, 2). Furthermore, those who eradicate SIBO see dramatic improvements in their symptoms(2). While there is a simple test for SIBO, the authors of the study did not test for it. This is ironic since FODMAPS should exacerbate SIBO and IBS symptoms by providing substrate for bacteria that make their way in to the small intestine to ferment, causing bloating and gas.
The second problem that was not tackled directly in this study was gluten sensitivity that presents with symptoms outside of the GI tract. Though gluten sensitivity and Celiac disease are both associated with GI symptoms, Celiac disease presents itself most typically with symptoms outside of the GI tract(3) and gluten sensitivity often presents itself with neurological symptoms and no GI symptoms(4). The brain is one of the most common sites for symptoms related to gluten sensitivity including headaches, brain fog, vertigo, and more(3). This study only looked at people with symptoms of IBS and suspected gluten sensitivity and left out people who may fit the criteria of gluten sensitivity with no GI symptoms. So people who see relief from vertigo, headaches, rashes, or any other manifestation of NCGS without IBS were not included in this study so the results don't pertain to them.
So what can we pull from this study? In the majority of people with symptoms of IBS and self-diagnosed gluten sensitivity, their GI symptoms may be caused by FODMAPS and not gluten. This does not rule out that they are sensitive to gluten as gluten sensitivity can present itself with symptoms outside of the GI tract, and it certainly doesn't rule out the existence of gluten sensitivity in the population since the study showed 8% of the subjects had gluten specific effects. The good news here is that a large chunk of people who think they are sensitive to gluten may have SIBO which is something that can be improved with a low FODMAP diet.
On the other side of the coin, people who eat a gluten free diet that contains grain-based foods with the gluten removed who still experience GI symptoms may want to look at reducing FODMAP intake as well. Dropping grains altogether as well as legumes and a few other fruits and vegetables for a brief period, as is seen in the specific carbohydrate diet, may fix the problem if SIBO is the culprit. Once the issue is fixed, a normal diet can resume.
If you learn anything from this study, it's that you should see a doctor rather than self-diagnose yourself with anything. Another thing you should pick up from the hoopla surrounding these articles based on a study is that the authors are trying to get clicks, they're not trying to be accurate. The title Gluten sensitivity doesn't exist is likely to grab more attention than Gluten sensitivity exists but maybe less than we thought because it will grab the attention of both people who have already decided it doesn't exist and people who have benefited from a gluten free diet. More clicks equals more $$$. It doesn't help that so few people even check the sources these authors cite in their work.
The final thing you should take home is that we are in the embryonic stages of gluten research, a knee jerk reaction based on a few bloggers' incorrect opinion of a study that didn't show what they say it showed isn't going to change the science. All it does is give you an incorrect opinion that goes against what the research and MDs working in this field are seeing on a day to day basis. Spreading it on social media without checking that it's accurate only increases the confusion and doesn't do a service to anyone.
As the research progresses I'm sure there will be further refinement since the criteria for diagnosis is so crude. This means that some people who are undertaking a gluten free diet may learn that gluten isn't a problem and their issue may be a much simpler fix that will allow them to eat foods they thought weren't right for them. I don't see how that's a bad thing, even if you don't want to eat gluten regularly I don't see why having the option is something you should preoccupy yourself with. On the flip side, if you don't believe gluten sensitivity exists, why not pick up some peer reviewed journals and read them? The internet isn't peer reviewed so any yahoo with a computer can print something and send it out to cyberspace, I'm living proof of that. :)
Confused about gluten? The dude who is the go to guy on gluten research just wrote a book that I referenced in this article and it clears up a lot of the confusion about the research. Take a look...
Gluten Freedom by Dr. Alessio Fasano
- Gluten may not be the primary trigger in grains that induces GI symptoms in susceptible individuals
- Most of the people who improve on a gluten free diet may be responding to reduced FODMAPS and not less gluten
- Gluten sensitivity is poorly defined and the criteria for diagnosis is terribly inaccurate
In the second part of the study, 22 subjects were given diets that increased FODMAP intake and included either gluten, whey, or no additional protein for 3 days and subjectively assessed for GI symptoms. All subjects received all 3 diets. This part of the study found that GI symptoms increased by similar levels in all groups with no specific response to gluten. However, there was an order effect which means that the order that a person received each diet had an effect on the results. In other words, people who received the diet with gluten first all had similar results to one another but different results than people who had whey or no gluten first.
So what does this study show? First off, this study supports the notion that NCGS exists, but that only a small number of people who respond positively to a gluten free diet are responding to lower gluten exposure. Instead, they may be responding to a reduction in FODMAP intake. But what does that mean?
First off, NCGS is poorly defined. To be diagnosed with NCGS you simply have to have symptoms of gluten sensitivity, not have celiac disease, and see an improvement in your symptoms with a gluten free diet. So anyone who has IBS or other GI problems who responds positively to removing gluten qualifies. There are 2 problems with this. The first problem is that a gluten free diet can mean many things. For some people it means removing grain-based foods, for others it means removing the gluten from grain-based foods.
If the culprit is specifically gluten, either one should work. The problem is, if it's not gluten and as this study suggests FODMAPS that are the problem for most people with GI symptoms, removing grain-based foods would be a successful approach while consuming grain-based foods with the gluten removed would have little effect since they would still contain FODMAPs. But why are FODMAPs a problem? The answer potentially lies in something called small intestinal bacterial overgrowth, or SIBO.
SIBO is a condition where bacteria overgrow in to the small intestine. While the large intestine houses a large number of bacteria, the small intestine houses far fewer in comparison. When an excessive amount of this bacteria begins to take up residence in the small intestine, people experience the same IBS symptoms associated with NCGS. In fact, some studies put the number of people with IBS who also have SIBO at approximately 80%(1, 2). Furthermore, those who eradicate SIBO see dramatic improvements in their symptoms(2). While there is a simple test for SIBO, the authors of the study did not test for it. This is ironic since FODMAPS should exacerbate SIBO and IBS symptoms by providing substrate for bacteria that make their way in to the small intestine to ferment, causing bloating and gas.
The second problem that was not tackled directly in this study was gluten sensitivity that presents with symptoms outside of the GI tract. Though gluten sensitivity and Celiac disease are both associated with GI symptoms, Celiac disease presents itself most typically with symptoms outside of the GI tract(3) and gluten sensitivity often presents itself with neurological symptoms and no GI symptoms(4). The brain is one of the most common sites for symptoms related to gluten sensitivity including headaches, brain fog, vertigo, and more(3). This study only looked at people with symptoms of IBS and suspected gluten sensitivity and left out people who may fit the criteria of gluten sensitivity with no GI symptoms. So people who see relief from vertigo, headaches, rashes, or any other manifestation of NCGS without IBS were not included in this study so the results don't pertain to them.
So what can we pull from this study? In the majority of people with symptoms of IBS and self-diagnosed gluten sensitivity, their GI symptoms may be caused by FODMAPS and not gluten. This does not rule out that they are sensitive to gluten as gluten sensitivity can present itself with symptoms outside of the GI tract, and it certainly doesn't rule out the existence of gluten sensitivity in the population since the study showed 8% of the subjects had gluten specific effects. The good news here is that a large chunk of people who think they are sensitive to gluten may have SIBO which is something that can be improved with a low FODMAP diet.
On the other side of the coin, people who eat a gluten free diet that contains grain-based foods with the gluten removed who still experience GI symptoms may want to look at reducing FODMAP intake as well. Dropping grains altogether as well as legumes and a few other fruits and vegetables for a brief period, as is seen in the specific carbohydrate diet, may fix the problem if SIBO is the culprit. Once the issue is fixed, a normal diet can resume.
Conclusion
Most of these articles professing that NCGS doesn't exist are sensationalizing the research that they use to try and support their preconceived notion. This study showed that most people who have self-diagnosed themselves with NCGS based on symptoms of IBS are not experiencing GI symptoms due to gluten. This is backed up by a study published earlier this year that found that only 1 in 4 people who self-diagnosed themselves with NCGS fit the criteria for diagnosis(5). Oddly the author of the article mentioned at the beginning of this blog took that as evidence that gluten sensitivity doesn't exist, which isn't the case. It doesn't surprise me that most people who self-diagnose themselves with gluten sensitivity don't have it. I'd imagine most people who self-diagnose themselves with aggressive colon cancer on WebMD don't have that either.If you learn anything from this study, it's that you should see a doctor rather than self-diagnose yourself with anything. Another thing you should pick up from the hoopla surrounding these articles based on a study is that the authors are trying to get clicks, they're not trying to be accurate. The title Gluten sensitivity doesn't exist is likely to grab more attention than Gluten sensitivity exists but maybe less than we thought because it will grab the attention of both people who have already decided it doesn't exist and people who have benefited from a gluten free diet. More clicks equals more $$$. It doesn't help that so few people even check the sources these authors cite in their work.
The final thing you should take home is that we are in the embryonic stages of gluten research, a knee jerk reaction based on a few bloggers' incorrect opinion of a study that didn't show what they say it showed isn't going to change the science. All it does is give you an incorrect opinion that goes against what the research and MDs working in this field are seeing on a day to day basis. Spreading it on social media without checking that it's accurate only increases the confusion and doesn't do a service to anyone.
As the research progresses I'm sure there will be further refinement since the criteria for diagnosis is so crude. This means that some people who are undertaking a gluten free diet may learn that gluten isn't a problem and their issue may be a much simpler fix that will allow them to eat foods they thought weren't right for them. I don't see how that's a bad thing, even if you don't want to eat gluten regularly I don't see why having the option is something you should preoccupy yourself with. On the flip side, if you don't believe gluten sensitivity exists, why not pick up some peer reviewed journals and read them? The internet isn't peer reviewed so any yahoo with a computer can print something and send it out to cyberspace, I'm living proof of that. :)
Confused about gluten? The dude who is the go to guy on gluten research just wrote a book that I referenced in this article and it clears up a lot of the confusion about the research. Take a look...
Gluten Freedom by Dr. Alessio Fasano
Thursday, February 27, 2014
The human's guide to being human: The problem with gluten
Gluten is a component in our food that seems to make it's way in to the headlines every day. What is gluten? Should you eat gluten? Is gluten really that bad? How can someone eat gluten for years with no problem and then all of a sudden begin reacting to it? These are all really good questions that deserve answers. Unfortunately, people know little about what gluten is, even those that have pulled it from their diet. In this blog we will take a look at gluten using the principles we have discussed in the "Human's Guide" series to help determine if gluten is really as bad for you as it's terrible reputation implies.
This is not to say that some gluten containing foods can't be part of an otherwise healthy diet. There are a couple of reasons that gluten seems to be causing issues in more people. For one, the dosages we are exposed to day in and day out have increased dramatically over the last few decades. Some of this is due to the fact that almost every meal we are exposed to contains gluten in some way. Eating breakfast cereal or bagels in the morning, sandwiches and pretzels for lunch, and pasta for dinner are about as American as apple pie.
Another reason we are exposed to larger doses is because genetically modifying wheat causes it to make more proteins, including gluten. A recent study found that people with irritable bowel syndrome who were given grain products made from an ancient form of wheat experienced an improvement in digestive symptoms while those who continued to eat modern grains did not(2). Finally, with the rise of heavily processed foods and a sharp drop in fruit and vegetable consumption, the American diet is about as diverse as a Ku Klux Klan meeting. These factors are all likely having a dramatic effect on our microbiome.
Prolamins are long proteins that are high in the amino acid L-Proline. What is interesting about this is that the human gut makes very little post-proline cleaving enzyme, an enzyme that helps break up larger proteins that contain L-Proline. Since our guts do not make a lot of this enzyme, we have a difficult time breaking up proteins that contain high levels of L-Proline. Since these long proteins are not broken down, we don't absorb them. This is where they become problematic, if we don't absorb them they make their way through our digestive tract in tact. When they make it to the large intestine, they can interact with bacteria there and wreak havoc on our microbiome.
In addition to reacting with the bacteria that make up our microbiome, gluten can interact with the intestinal wall which causes the release of a protein called zonulin. In turn, zonulin causes areas between cells of the intestinal wall called tight junctions to dissolve, increasing the permeability of the intestine to the contents within it. This allows the contents of your digestive tract to react with the immune system, 80% of which is located in the gut. This causes you to begin reacting to larger proteins that are not meant to enter your bloodstream, as shown below.
The research of Dr. Alessio Fasano, the man who identified the protein zonulin as the cause of "leaky gut" and a major contributing factor to celiac disease and gluten sensitivity, notes that when gluten interacts with the intestinal wall of all people, it causes the release of zonulin(2). In a healthy person, the tight junctions are resealed very quickly, in a person with celiac disease or gluten sensitivity, it takes much longer. Dr. Fasano believes that gut dysbiosis, aka an altered gut microbiome, is a potential cause of this delayed sealing of the tight junctions. There is indirect evidence that continually assaulting the microbiome with undigested proteins, particularly ones high in the amino acid L-Proline, may be able to trigger gut dysbiosis over time. To illustrate this, let's take a look at just one of the thousands of species of bacteria that makes it's residence in your gut.
Under alkaline conditions, such as those found toward the end of the large intestine, both the yeast and fungal forms of Candida Albicans contain a transport system for the amino acid L-Proline(3, 4). L-Proline uptake induces the conversion of the yeast form of Candida Albicans in to the fungal form(5, 6). Other amino acids do as well, including L-Glutamine, but L-Proline has the greatest effect. In addition to free L-Proline, Candida Albicans is able to bind to the L-Proline found in larger proteins(7) that make their way to the colon undigested, which likely includes gluten. Since Candida Albicans contains the enzyme L-Proline aminopeptidase, it is able to break L-Proline from these larger proteins(8) and induce fungal transformation.
Under more acidic conditions, such as those found at the beginning of the large intestine, Candida Albicans remains in it's yeast form as the change from yeast to fungus is blocked or reversed in acidic conditions(6). However, as a byproduct of amino acid fermentation, fungal Candida Albicans secretes ammonia which allows it to alkalinize the environment it is in(9). This could allow fungal Candida Albicans to work it's way back up the digestive tract in to areas where it formerly couldn't convert in to it's fungal form provided enough amino acids and L-Proline are provided to promote alkalinization and fungal conversion.
A major factor of genetic expression that is determined by which form Candida Albicans is in is the gene for hyphal wall protein 1(HWP1). HWP1 gene expression is very high in the fungal form of Candida Albicans but either not present or present in low amounts in the yeast form(10, 11). HWP1 allows Candida Albicans to bind to the intestinal wall of it's host as well as tissues inside the body if it enters the bloodstream. This could allow the fungal form of Candida Albicans to set up shop at the end of the large intestine while providing a continuous supply of undigested proteins high in the amino acid L-Proline from gluten could allow fungal Candida Albicans to alkalinize it's environment enough to work it's way back to formerly uninhabitable regions of the large intestine. Ironically enough, fungal Candida Albicans has been implicated as a trigger for celiac disease as HWP1 has protein structures similar to the ones found in gluten that trigger an adaptive immune response(11).
These SCFAs have several important roles in intestinal health. First, butyric acid is the preferred fuel for the cells of the digestive tract. Butyric acid has been shown to improve peristaltic action by increasing contraction of the smooth muscle in the large intestine(12), but acetic acid is just as effective at a lower dose(13). It is important to note that constipation, a common complaint of people with GI problems, is effectively a defect of intestinal peristalsis.
SCFAs, particularly butyric acid, have a direct effect on intestinal permeability. Butyric acid increases the expression of tight junction proteins in intestinal cells whose tight junctions have been dissolved, re-sealing the intestinal wall and decreasing intestinal permeability(14). SCFAs also indirectly reduce intestinal permeability through reducing inflammation in the digestive tract by promoting anti-inflammatory gene expression(15). Increases in intestinal inflammation lead to an increase in systemic inflammation that increase intestinal permeability, allowing the contents of the intestine to react with the immune system. When you get diarrhea, increased intestinal permeability fills the large intestine with water to flush it out.
Bloating aside, there is experimental evidence that ammonia has a negative effect on intestinal health. Cells of the rat colon cannot effectively metabolize SCFAs in the presence of ammonia when glucose levels are low, as would be the case toward the end of the large intestine(16). In the absence of a healthy microbiome or the fermentable fibers that these types of bacteria use, ammonia levels can climb and ammonia can react with the cells of the intestinal wall. By lowering the pH of the large intestine, SCFAs can help regulate the amount of ammonia being created as many of the amino acid fermenting bacteria that create ammonia, fungal Candida Albicans included, are inhibited by SCFAs and the acidic environment they create(17, 18, 19).
This is not to say that protein is the devil or that this process was always bad. High levels of protein fermenting bacteria are associated with inflammation, which in turn is associated with insulin resistance. While this is not necessarily a good thing now that food is plentiful, going in to the leaner months insulin resistant when food was scarce was likely a beneficial thing. Consider it a way to activate the "thrifty" genotype. Since both grains and legumes keep for much longer than fresh fruits and vegetables and are an acceptable nutrient containing food source, they may have been necessary for our survival in northern climates and the shifting food supply caused by weather before modern technology made most food available year round. There is, however, a distinct difference between doing this for 4-5 months out of the year and doing it chronically over the course of decades.
Many people who undergo long term low carb diets notice an increase in their blood glucose despite not eating any carbohydrates. It has been postulated that this is due to gluconeogenesis, the creation of glucose from protein, and something called physiological insulin resistance, a way that the body spares glucose for the brain. This may not necessarily be something that is orchestrated at the level of the individual cell or even within the body at all. The brain and gut are connected by the vagus nerve which is a conduit for communication between the bacteria in our gut and the brain. Much of this phenomenon known as physiological insulin resistance may be orchestrated in the gut by the resident bacteria.
Reducing the amount of undigested protein that enters the large intestine is likely a good idea over the long term, but that doesn't mean that bread or pasta can't be part of a healthy diet. To the contrary, in the face of a highly diverse diet, I believe that these foods can be enjoyed in moderation. In addition, I believe that one can reverse gluten sensitivity under the right dietary conditions. I am currently working on a program for this, and I don't believe that people with non-celiac gluten sensitivity need to spend years fixing the problem provided they are manipulating the proper variables. We'll see how it goes.
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What is gluten and why is it problematic?
Gluten is a protein found in wheat that gives dough it's elastic qualities. What most people don't know is that gluten is a catch-all term that refers to storage proteins found in wheat, barley, rye, and other grains that are called prolamins(1). While not everyone reacts negatively to these storage proteins, they can often become problematic because humans cannot digest them. Over time, this can cause people to suddenly begin reacting to gluten as well as other difficult to digest proteins such as the casein in milk or the globulins in legumes which are essentially their storage proteins. This is why gluten sensitivity is likely a progressive issue and also why people with gluten tolerance issues tend to react to other problematic proteins.This is not to say that some gluten containing foods can't be part of an otherwise healthy diet. There are a couple of reasons that gluten seems to be causing issues in more people. For one, the dosages we are exposed to day in and day out have increased dramatically over the last few decades. Some of this is due to the fact that almost every meal we are exposed to contains gluten in some way. Eating breakfast cereal or bagels in the morning, sandwiches and pretzels for lunch, and pasta for dinner are about as American as apple pie.
Another reason we are exposed to larger doses is because genetically modifying wheat causes it to make more proteins, including gluten. A recent study found that people with irritable bowel syndrome who were given grain products made from an ancient form of wheat experienced an improvement in digestive symptoms while those who continued to eat modern grains did not(2). Finally, with the rise of heavily processed foods and a sharp drop in fruit and vegetable consumption, the American diet is about as diverse as a Ku Klux Klan meeting. These factors are all likely having a dramatic effect on our microbiome.
Protein digestion and gluten
Proteins are long strings of amino acids that are broken in to smaller peptides by our stomach acid and pepsin, a protein enzyme secreted by our stomach, as well as other protein enzymes in the small intestine. In order for protein to be absorbed, it must be broken up in to it's constituent amino acids or peptide chains of no more than 4 amino acids. Any protein that is not broken down in to small enough parts in the small intestine will make it to the large intestine where they are free to interact with the resident bacteria there.Prolamins are long proteins that are high in the amino acid L-Proline. What is interesting about this is that the human gut makes very little post-proline cleaving enzyme, an enzyme that helps break up larger proteins that contain L-Proline. Since our guts do not make a lot of this enzyme, we have a difficult time breaking up proteins that contain high levels of L-Proline. Since these long proteins are not broken down, we don't absorb them. This is where they become problematic, if we don't absorb them they make their way through our digestive tract in tact. When they make it to the large intestine, they can interact with bacteria there and wreak havoc on our microbiome.
In addition to reacting with the bacteria that make up our microbiome, gluten can interact with the intestinal wall which causes the release of a protein called zonulin. In turn, zonulin causes areas between cells of the intestinal wall called tight junctions to dissolve, increasing the permeability of the intestine to the contents within it. This allows the contents of your digestive tract to react with the immune system, 80% of which is located in the gut. This causes you to begin reacting to larger proteins that are not meant to enter your bloodstream, as shown below.
The research of Dr. Alessio Fasano, the man who identified the protein zonulin as the cause of "leaky gut" and a major contributing factor to celiac disease and gluten sensitivity, notes that when gluten interacts with the intestinal wall of all people, it causes the release of zonulin(2). In a healthy person, the tight junctions are resealed very quickly, in a person with celiac disease or gluten sensitivity, it takes much longer. Dr. Fasano believes that gut dysbiosis, aka an altered gut microbiome, is a potential cause of this delayed sealing of the tight junctions. There is indirect evidence that continually assaulting the microbiome with undigested proteins, particularly ones high in the amino acid L-Proline, may be able to trigger gut dysbiosis over time. To illustrate this, let's take a look at just one of the thousands of species of bacteria that makes it's residence in your gut.
Candida Albicans: A day in the life of a commensal organism
Candida Albicans is a commensal organism, it lives in the human mouth and digestive tract and typically causes no problems to the human it benefits from. However, Candida Albicans is able to convert back and forth between a yeast and a fungus depending on the environmental conditions it is in. In it's yeast form, it is basically benign and may even provide some benefit to the host. However, under certain environmental conditions, it changes from a yeast to a fungus where it can cause major problems and invade tissues. In this way, what makes it's way through your digestive tract is critically important to the state of Candida Albicans because it affects the environmental conditions that it lives in, and thus affects the genes that are expressed. But what causes Candida Albicans to morph from it's benign yeast form in to it's problematic fungal form?Under alkaline conditions, such as those found toward the end of the large intestine, both the yeast and fungal forms of Candida Albicans contain a transport system for the amino acid L-Proline(3, 4). L-Proline uptake induces the conversion of the yeast form of Candida Albicans in to the fungal form(5, 6). Other amino acids do as well, including L-Glutamine, but L-Proline has the greatest effect. In addition to free L-Proline, Candida Albicans is able to bind to the L-Proline found in larger proteins(7) that make their way to the colon undigested, which likely includes gluten. Since Candida Albicans contains the enzyme L-Proline aminopeptidase, it is able to break L-Proline from these larger proteins(8) and induce fungal transformation.
Under more acidic conditions, such as those found at the beginning of the large intestine, Candida Albicans remains in it's yeast form as the change from yeast to fungus is blocked or reversed in acidic conditions(6). However, as a byproduct of amino acid fermentation, fungal Candida Albicans secretes ammonia which allows it to alkalinize the environment it is in(9). This could allow fungal Candida Albicans to work it's way back up the digestive tract in to areas where it formerly couldn't convert in to it's fungal form provided enough amino acids and L-Proline are provided to promote alkalinization and fungal conversion.
A major factor of genetic expression that is determined by which form Candida Albicans is in is the gene for hyphal wall protein 1(HWP1). HWP1 gene expression is very high in the fungal form of Candida Albicans but either not present or present in low amounts in the yeast form(10, 11). HWP1 allows Candida Albicans to bind to the intestinal wall of it's host as well as tissues inside the body if it enters the bloodstream. This could allow the fungal form of Candida Albicans to set up shop at the end of the large intestine while providing a continuous supply of undigested proteins high in the amino acid L-Proline from gluten could allow fungal Candida Albicans to alkalinize it's environment enough to work it's way back to formerly uninhabitable regions of the large intestine. Ironically enough, fungal Candida Albicans has been implicated as a trigger for celiac disease as HWP1 has protein structures similar to the ones found in gluten that trigger an adaptive immune response(11).
Fungal Candida Albicans and gastrointestinal health
Fungal Candida Albicans can negatively impact digestive health in many ways. In order to better understand how, we first have to take a look at what the beneficial bacteria are doing in your gut to promote gastrointestinal health. There are thousands of different types of bacteria in your gut, but some of the best studied belong to the genus Bifidobacterium. Bifidobacteria ferment undigested carbohydrates such as soluble fiber and resistant starch in to short-chained fatty acids(SCFAs) such as butyric acid, acetic acid, and propionic acid.These SCFAs have several important roles in intestinal health. First, butyric acid is the preferred fuel for the cells of the digestive tract. Butyric acid has been shown to improve peristaltic action by increasing contraction of the smooth muscle in the large intestine(12), but acetic acid is just as effective at a lower dose(13). It is important to note that constipation, a common complaint of people with GI problems, is effectively a defect of intestinal peristalsis.
SCFAs, particularly butyric acid, have a direct effect on intestinal permeability. Butyric acid increases the expression of tight junction proteins in intestinal cells whose tight junctions have been dissolved, re-sealing the intestinal wall and decreasing intestinal permeability(14). SCFAs also indirectly reduce intestinal permeability through reducing inflammation in the digestive tract by promoting anti-inflammatory gene expression(15). Increases in intestinal inflammation lead to an increase in systemic inflammation that increase intestinal permeability, allowing the contents of the intestine to react with the immune system. When you get diarrhea, increased intestinal permeability fills the large intestine with water to flush it out.
Candida Albicans and acid/base reactions
The roles of the SCFAs are important to know because ammonia effectively eliminates them. We all had the chance to experience, firsthand, the effects of combining acids and bases when we were in elementary school. For those of you foggy on the details, the pseudo-volcano many of us made in science class out of baking soda and vinegar is a prime example of an acid/base reaction. Baking soda, with a pH of 8.3, and vinegar, with a pH of 2.4, react and cause the rapid fizzing that resembles a volcanic eruption when placed in a partially enclosed cylinder with the top removed. Could this same effect be one of the causes of the bloating many people with gluten sensitivity experience when exposed to the proteins in gluten? Could it also be why beans, containing both hard to digest proteins as well as fiber, tend to bloat and cause gas? It is interesting to note that vinegar is made from acetic acid, one of the SCFAs our beneficial bacteria make, and ammonia has a much higher pH of 11.0 than baking soda, which would cause a greater reaction than baking soda.Bloating aside, there is experimental evidence that ammonia has a negative effect on intestinal health. Cells of the rat colon cannot effectively metabolize SCFAs in the presence of ammonia when glucose levels are low, as would be the case toward the end of the large intestine(16). In the absence of a healthy microbiome or the fermentable fibers that these types of bacteria use, ammonia levels can climb and ammonia can react with the cells of the intestinal wall. By lowering the pH of the large intestine, SCFAs can help regulate the amount of ammonia being created as many of the amino acid fermenting bacteria that create ammonia, fungal Candida Albicans included, are inhibited by SCFAs and the acidic environment they create(17, 18, 19).
Conclusion
While this blog has focused on the interaction between gluten and Candida Albicans in the gut, the intent is not to target any specific commensal organism as the culprit. Candida Albicans happens to be one of the few commensals we know a lot about because it has been studied at length. There are thousands of different types of bacteria in your gut, and we have data on very few of them. Any of the bacteria in your gut that can ferment amino acids are likely to have a negative effect on gut health if they overgrow simply because it is likely that they create ammonia. Ammonia is made from 1 molecule of nitrogen and 3 molecules of hydrogen, and protein is the only macronutrient that contains nitrogen.This is not to say that protein is the devil or that this process was always bad. High levels of protein fermenting bacteria are associated with inflammation, which in turn is associated with insulin resistance. While this is not necessarily a good thing now that food is plentiful, going in to the leaner months insulin resistant when food was scarce was likely a beneficial thing. Consider it a way to activate the "thrifty" genotype. Since both grains and legumes keep for much longer than fresh fruits and vegetables and are an acceptable nutrient containing food source, they may have been necessary for our survival in northern climates and the shifting food supply caused by weather before modern technology made most food available year round. There is, however, a distinct difference between doing this for 4-5 months out of the year and doing it chronically over the course of decades.
Many people who undergo long term low carb diets notice an increase in their blood glucose despite not eating any carbohydrates. It has been postulated that this is due to gluconeogenesis, the creation of glucose from protein, and something called physiological insulin resistance, a way that the body spares glucose for the brain. This may not necessarily be something that is orchestrated at the level of the individual cell or even within the body at all. The brain and gut are connected by the vagus nerve which is a conduit for communication between the bacteria in our gut and the brain. Much of this phenomenon known as physiological insulin resistance may be orchestrated in the gut by the resident bacteria.
Reducing the amount of undigested protein that enters the large intestine is likely a good idea over the long term, but that doesn't mean that bread or pasta can't be part of a healthy diet. To the contrary, in the face of a highly diverse diet, I believe that these foods can be enjoyed in moderation. In addition, I believe that one can reverse gluten sensitivity under the right dietary conditions. I am currently working on a program for this, and I don't believe that people with non-celiac gluten sensitivity need to spend years fixing the problem provided they are manipulating the proper variables. We'll see how it goes.
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Thursday, October 31, 2013
Gluten: How to determine if you should avoid it
Over the course of the last few years, many people have removed gluten from their diet and noticed dramatic changes in their health. In response, the food industry has flooded the market with gluten free items ranging from bread to cookies to pasta. Many people look at this shift to gluten free eating as a fad, but is there something more to it? Is gluten a problem for everyone, or should some people be more vigilant than others? Let's take a look at gluten and some things you should be on the lookout for to determine if gluten is something you should avoid.
In addition to celiac disease, there is a condition called non-celiac gluten sensitivity that some people experience. People with non-celiac gluten sensitivity react to gluten, their reaction just isn't quite as severe as people with celiac disease. But how common is this? It's really hard to say. Even for a concrete condition like celiac disease, it's very difficult to diagnose because different people tend to have different symptoms and lab tests are not currently up to snuff. While most people with celiac disease have digestive symptoms, not all do(1). For some people, symptoms can involve rashes and for others symptoms can be neurological. In addition, the symptoms differ for adults and children. Since it is so difficult to categorize the symptoms of celiac disease, the less severe reaction seen in non-celiac gluten sensitivity makes it even more difficult to pin down.
Some research points to gluten being a potential problem for most people. Eighty percent of humans produce zonulin and intestinal tissue samples from both celiacs and non-celiacs produce zonulin when treated with gluten(3). The reason people with celiac disease have a more severe reaction than people without celiac disease appears to be because the intestinal permeability related to zonulin lasts much longer in celiacs than non-celiacs. We know that the beneficial bacteria within the gut ferment plant fibers that we can't digest in to short chained fatty acids that repair the tight junctions between cells of the intestinal wall. In people with gut dysboisis, the composition of gut bacteria is changed and can lead to digestive problems and there is evidence that people with celiac disease have gut dysbiosis(4). Perhaps this is one of the reasons that zonulin has a greater effect on people with celiac disease than those without it.
Zonulin is not the only thing that causes a problem in the intestinal wall, inflammation also causes the integrity of the intestinal barrier to be compromised. Obese people tend to have increased levels of inflammation as well as a population of gut bacteria that make this inflammation worse. They also tend to have higher levels of zonulin circulating in their blood(5). There have been many studies in mice showing that simply giving the bacteria of lean mice to obese mice not only made the obese mice lean, it also decreased systemic inflammation. This effect is also dependent on diet(6). Obese mice who eat a diet low in vegetable fiber don't get the benefits from ingesting the bacteria from the lean mice. In the future, fecal transplants may be capable of putting a person with celiac disease in to remission, allowing them to eat wheat with no problem, but we aren't there yet and it would still require a change in diet. Of the factors that a person can manipulate, diet is currently the best option.
Other conditions associated with intestinal permeability and, therefore, linked to gluten sensitivity include most autoimmune diseases including asthma, rheumatoid arthritis, Type 1 diabetes, Lupus, seasonal allergies, and multiple sclerosis. It is theorized that one of the conditions underlying all autoimmune diseases is intestinal permeability so removing gluten is prudent if you have one of these conditions. In addition to autoimmune disorders, people with irritable bowel syndrome/disorders should also avoid gluten due to high levels of intestinal inflammation and potential gut dysbiosis.
Type 2 diabetes and obesity are associated with higher levels of inflammation and zonulin and could also be related to gluten sensitivity. Since zonulin also regulates the tight junctions of the blood brain barrier and the lungs(7), people with a family history of Alzheimer's disease or who have frequent respiratory infections should probably limit their exposure to gluten. Finally, high stress levels as well as increased age are related to changes in both gut bacteria as well as immune system function and may impact a person's sensitivity to gluten. A recent study showed smoking cessation can lead to the same changes in gut bacteria that is associated with obesity(8), so if you plan on quitting smoking it may be a good idea to limit gluten exposure during this time,
While this is certainly quite a list of possible issues that gluten sensitivity can contribute to, the treatment is the same: Remove gluten and consume more vegetables. Note that the solution isn't to start consuming gluten free snacks, as they will only contribute to gut dysbiosis by not providing soluble fibes for the good bacteria in your gut to ferment. While probiotics are also an attractive option, there is no point in taking them unless you are eating foods that will support their proliferation in your gut. In time, I believe quite a few people who are sensitive to gluten can tolerate it once they re-establish the proper balance of bacteria in their gut. For some people this will be easier than others depending on which other foods they are sensitive to and how much damage they have caused.
What is gluten?
Gluten is a protein that contains gliadin and is found in certain grains including wheat, barley, and rye. Gluten is a storage protein, also called a prolamin. In fact, all grains have prolamins, the reason we know a lot about gluten is because of it's relationship with celiac disease. When the gliadin found in gluten interacts with the intestinal wall of people with celiac disease, it causes the release of zonulin, a protein that opens up the intestinal wall and allows the contents of the intestine to react with the immune system. This is called intestinal permeability. It does this by dissolving tight junctions between cells that seal the contents of the intestine and prevent it's contents from reacting with the immune system. This is a less than ideal scenario obviously, but should people without celiac disease be concerned?In addition to celiac disease, there is a condition called non-celiac gluten sensitivity that some people experience. People with non-celiac gluten sensitivity react to gluten, their reaction just isn't quite as severe as people with celiac disease. But how common is this? It's really hard to say. Even for a concrete condition like celiac disease, it's very difficult to diagnose because different people tend to have different symptoms and lab tests are not currently up to snuff. While most people with celiac disease have digestive symptoms, not all do(1). For some people, symptoms can involve rashes and for others symptoms can be neurological. In addition, the symptoms differ for adults and children. Since it is so difficult to categorize the symptoms of celiac disease, the less severe reaction seen in non-celiac gluten sensitivity makes it even more difficult to pin down.
Is gluten sensitivity becoming more common?
One of the first things people point out when discussing the rise in celiac disease is that we are simply better at diagnosing it. A study carried out in 2009 showed that the rise isn't simply a matter of better diagnosis. Researchers looked at the blood of Air Force personnel collected from 1948 to 1954 and compared it to the recently collected blood of people from Minnesota of similar age to determine if the prevalence of undiagnosed celiac disease has increased or if the increase was simply due to better diagnosis. The researchers found that the people from Minnesota were more than 4x more likely to have the antibodies associated with celiac disease in their blood than the Air Force personnel(2). This suggests that there is something else at play other than better diagnosis.How can you go from not reacting to gluten to having a reaction
One of the more frustrating things about gluten sensitivity is that people can eat gluten for many years without having a problem and then all of a sudden begin reacting to it. One thing that gets brought up when people feel they may be reacting negatively to gluten is that the condition is new. How can someone seemingly go from having absolutely no reaction to gluten at all to having one so severe that they can't function normally? The key to gluten sensitivity, celiac or otherwise, may lie with the trillions of bacteria that reside in your gut, and there is ample evidence to suggest so.Some research points to gluten being a potential problem for most people. Eighty percent of humans produce zonulin and intestinal tissue samples from both celiacs and non-celiacs produce zonulin when treated with gluten(3). The reason people with celiac disease have a more severe reaction than people without celiac disease appears to be because the intestinal permeability related to zonulin lasts much longer in celiacs than non-celiacs. We know that the beneficial bacteria within the gut ferment plant fibers that we can't digest in to short chained fatty acids that repair the tight junctions between cells of the intestinal wall. In people with gut dysboisis, the composition of gut bacteria is changed and can lead to digestive problems and there is evidence that people with celiac disease have gut dysbiosis(4). Perhaps this is one of the reasons that zonulin has a greater effect on people with celiac disease than those without it.
Other factors affecting intestinal wall integrity
Aside from gluten, there is another trigger that causes zonulin to dissolve the tight junctions between cells of the intestinal wall. When bacteria overgrow from the large intestine in to the small intestine, or when pathogenic bacteria overpopulate and beneficial ones underpopulate, zonulin opens up the tight junctions to pull water in to the intestine to flush the pathogenic bacteria out. A recent article in the NY Times went through quite a bit of the current theories on celiac disease and a change in gut bacteria is right up at the forefront. Not only can it impact a person's ability to re-seal the tight junctions, but it can compound the effect zonulin has on intestinal permeablity.Zonulin is not the only thing that causes a problem in the intestinal wall, inflammation also causes the integrity of the intestinal barrier to be compromised. Obese people tend to have increased levels of inflammation as well as a population of gut bacteria that make this inflammation worse. They also tend to have higher levels of zonulin circulating in their blood(5). There have been many studies in mice showing that simply giving the bacteria of lean mice to obese mice not only made the obese mice lean, it also decreased systemic inflammation. This effect is also dependent on diet(6). Obese mice who eat a diet low in vegetable fiber don't get the benefits from ingesting the bacteria from the lean mice. In the future, fecal transplants may be capable of putting a person with celiac disease in to remission, allowing them to eat wheat with no problem, but we aren't there yet and it would still require a change in diet. Of the factors that a person can manipulate, diet is currently the best option.
What to be on the lookout for
As mentioned above, a diet low in soluble fiber from fruits and vegetables can cause gut dysbiosis over a long period of time. Frequent use of antibiotics, currently or in the past, also can have an affect. In addition, other factors out of your control can increase your likelihood of becoming sensitive to gluten through changes in gut bacteria. Being born by C-section and not being breastfed increase a person's likelihood of gut dysbiosis later in life, so people who satisfy either or both conditions should be vigilant and consume a diet high in vegetables. In addition, if your mother was obese she could have passed on her less than ideal gut bacteria to you in the event you were born vaginally.Other conditions associated with intestinal permeability and, therefore, linked to gluten sensitivity include most autoimmune diseases including asthma, rheumatoid arthritis, Type 1 diabetes, Lupus, seasonal allergies, and multiple sclerosis. It is theorized that one of the conditions underlying all autoimmune diseases is intestinal permeability so removing gluten is prudent if you have one of these conditions. In addition to autoimmune disorders, people with irritable bowel syndrome/disorders should also avoid gluten due to high levels of intestinal inflammation and potential gut dysbiosis.
Type 2 diabetes and obesity are associated with higher levels of inflammation and zonulin and could also be related to gluten sensitivity. Since zonulin also regulates the tight junctions of the blood brain barrier and the lungs(7), people with a family history of Alzheimer's disease or who have frequent respiratory infections should probably limit their exposure to gluten. Finally, high stress levels as well as increased age are related to changes in both gut bacteria as well as immune system function and may impact a person's sensitivity to gluten. A recent study showed smoking cessation can lead to the same changes in gut bacteria that is associated with obesity(8), so if you plan on quitting smoking it may be a good idea to limit gluten exposure during this time,
While this is certainly quite a list of possible issues that gluten sensitivity can contribute to, the treatment is the same: Remove gluten and consume more vegetables. Note that the solution isn't to start consuming gluten free snacks, as they will only contribute to gut dysbiosis by not providing soluble fibes for the good bacteria in your gut to ferment. While probiotics are also an attractive option, there is no point in taking them unless you are eating foods that will support their proliferation in your gut. In time, I believe quite a few people who are sensitive to gluten can tolerate it once they re-establish the proper balance of bacteria in their gut. For some people this will be easier than others depending on which other foods they are sensitive to and how much damage they have caused.
Thursday, October 10, 2013
Why Paleo? The primary reason I avoid grains and legumes.
I was recently having a discussion with a few people on the reasons I eat a Paleo diet. Like most discussions on religion and politics, it quickly degraded in to more of a name calling contest. Rather than get involved in any of that, I simply provided my case and let it be. However, I realized there's probably quite a few people who don't know why they are eating Paleo or why it may be a healthier way of eating. In this blog we will go over why much of the data you read on nutrition is probably wrong, why there is a lack of evidence for Paleo, and the primary reason grains and legumes are probably not wise nutritional choices if health is your goal.
Many people point to the data that shows grains and legumes to be healthy food options. The problem is this data doesn't show what they propose that it does. Most of this data is epidemiological data. The researchers provide food questionnaires that people fill out and the researchers compare this data to predetermined health outcomes. There are many problems with this type of data. The primary reason it is faulty is that the researchers are not controlling extraneous variables. For example, if you tell a population that whole grains are healthy, people who are interested in health will gravitate towards eating whole grains. People who are interested in health also tend to exercise, limit alcohol consumption, don't smoke, and keep a pretty regular sleep schedule. As such, these people will skew the results toward better health outcomes, not necessarily because whole grains are healthy, but because these people lead otherwise healthy lives. Because of this, epidemiological can show that there is a relationship between two variables, it cannot say the direction of the relationship. In other words, it could be that people who eat whole grains are healthy, but it could also be that people who are healthy eat whole grains. This means that this type of data is good for establishing relationships that can be further studied in a controlled clinical trial, not to say whether something is healthy to consume or not.
The other studies typically cited to show that grains or legumes are healthy foods don't have a proper control group. When you are trying to determine whether something is beneficial or not, you would want to compare a diet that is otherwise identical between two groups with the exception that one group contains that food and the other doesn't. Obviously this is very difficult to do, few people want to be locked in a metabolic ward and have their food weighed and prepared for them for long periods of time. In addition, you would have to do these studies over very long periods of time which is probably not something you're going to see happen. This is why most of the data is epidemiological. Of the few studies we have, none compare eating whole grains to eating no grains, they compare eating whole grains to refined grains. If a study shows a difference between the two, and most do, it doesn't necessarily mean that the one that is better is a healthy food. If you ran a study and compared heroin to crack and heroine was better than crack, that wouldn't make crack a healthy option, only healthier than crack.
This presents a problem. At the end of the day, research is unlikely to give us solid answers as to what is healthy. So if the studies don't appear to be of any help, how do you make a decision? When studies are of no help you want to look at mechanism. Mechanism refers to a specific way that something could lead to beneficial or bad health outcomes. The criteria I use is whether a food provides a wide range of essential nutrients, contains some nutrient that is hard to get from other foods, or contains some nonessential nutrient that provides a health benefit. When you look at grains and legumes, none of these apply. For a more thorough explanation of why watch this.
Now, is there something in grains or legumes that should give you reservations in consuming them? Many things have been brought up that really didn't pan out in the research such as phytic acid and lectins. However, there is one potential issue that has been supported by the research that should give you concern with consuming grains or legumes. Grains and legumes contain hard to digest storage proteins called prolamins. Humans do not produce enough of the enzymes used to digest these proteins so they pretty much go through the intestinal tract untouched. Gluten is probably the best known prolamin, is contained in wheat, and causes major problems in people with celiac disease. This may not seem like an issue, but these prolamins have other insidious properties. All of the prolamins in grains, particularly the gliadin in gluten, are immunogenic. In fact, gluten will elicit an immune response, and it will do this in all people whether they have celiac disease or not(1). This doesn't mean they are necessarily toxic, but firing off the immune system without reason shouldn't be one of your primary nutritional goals if health is your goal. The prolamins in legumes haven't been specifically studied, but given that their structure is basically the same as the prolamins in grains, I see no reason to test the waters.
If grains and legumes provided something you couldn't get elsewhere, were loaded with nutrients that are hard to get, or possessed some phytonutrient that is of benefit I would say go ahead and eat them. But their lack of nutrient density coupled with their immunogenic properties give me good reason to not recommend people consume them on a regular basis, and certainly not as a staple in their diet. Will you die if you eat a sandwich? Nope. Are you ever going to find a solid clinical study showing them to be unhealthy over the long term? Probably not. Just ask yourself, would you submit yourself to stay in a metabolic ward away from your family for 6-9 months while you eat a strict diet of measured food that may or may not contain legumes or grains. Do you think researchers are going to find 100 people to do so and who would fund that study? If the day ever comes that we see that study and the data supports grain and legume consumption I'll be all in. Until that day, I am going to go with my N=1 study that shows I am missing nothing from passing on those foods and potentially improving my health by avoiding them. I certainly feel better, have more energy, and get sick far less often.
Many people point to the data that shows grains and legumes to be healthy food options. The problem is this data doesn't show what they propose that it does. Most of this data is epidemiological data. The researchers provide food questionnaires that people fill out and the researchers compare this data to predetermined health outcomes. There are many problems with this type of data. The primary reason it is faulty is that the researchers are not controlling extraneous variables. For example, if you tell a population that whole grains are healthy, people who are interested in health will gravitate towards eating whole grains. People who are interested in health also tend to exercise, limit alcohol consumption, don't smoke, and keep a pretty regular sleep schedule. As such, these people will skew the results toward better health outcomes, not necessarily because whole grains are healthy, but because these people lead otherwise healthy lives. Because of this, epidemiological can show that there is a relationship between two variables, it cannot say the direction of the relationship. In other words, it could be that people who eat whole grains are healthy, but it could also be that people who are healthy eat whole grains. This means that this type of data is good for establishing relationships that can be further studied in a controlled clinical trial, not to say whether something is healthy to consume or not.
The other studies typically cited to show that grains or legumes are healthy foods don't have a proper control group. When you are trying to determine whether something is beneficial or not, you would want to compare a diet that is otherwise identical between two groups with the exception that one group contains that food and the other doesn't. Obviously this is very difficult to do, few people want to be locked in a metabolic ward and have their food weighed and prepared for them for long periods of time. In addition, you would have to do these studies over very long periods of time which is probably not something you're going to see happen. This is why most of the data is epidemiological. Of the few studies we have, none compare eating whole grains to eating no grains, they compare eating whole grains to refined grains. If a study shows a difference between the two, and most do, it doesn't necessarily mean that the one that is better is a healthy food. If you ran a study and compared heroin to crack and heroine was better than crack, that wouldn't make crack a healthy option, only healthier than crack.
This presents a problem. At the end of the day, research is unlikely to give us solid answers as to what is healthy. So if the studies don't appear to be of any help, how do you make a decision? When studies are of no help you want to look at mechanism. Mechanism refers to a specific way that something could lead to beneficial or bad health outcomes. The criteria I use is whether a food provides a wide range of essential nutrients, contains some nutrient that is hard to get from other foods, or contains some nonessential nutrient that provides a health benefit. When you look at grains and legumes, none of these apply. For a more thorough explanation of why watch this.
Now, is there something in grains or legumes that should give you reservations in consuming them? Many things have been brought up that really didn't pan out in the research such as phytic acid and lectins. However, there is one potential issue that has been supported by the research that should give you concern with consuming grains or legumes. Grains and legumes contain hard to digest storage proteins called prolamins. Humans do not produce enough of the enzymes used to digest these proteins so they pretty much go through the intestinal tract untouched. Gluten is probably the best known prolamin, is contained in wheat, and causes major problems in people with celiac disease. This may not seem like an issue, but these prolamins have other insidious properties. All of the prolamins in grains, particularly the gliadin in gluten, are immunogenic. In fact, gluten will elicit an immune response, and it will do this in all people whether they have celiac disease or not(1). This doesn't mean they are necessarily toxic, but firing off the immune system without reason shouldn't be one of your primary nutritional goals if health is your goal. The prolamins in legumes haven't been specifically studied, but given that their structure is basically the same as the prolamins in grains, I see no reason to test the waters.
If grains and legumes provided something you couldn't get elsewhere, were loaded with nutrients that are hard to get, or possessed some phytonutrient that is of benefit I would say go ahead and eat them. But their lack of nutrient density coupled with their immunogenic properties give me good reason to not recommend people consume them on a regular basis, and certainly not as a staple in their diet. Will you die if you eat a sandwich? Nope. Are you ever going to find a solid clinical study showing them to be unhealthy over the long term? Probably not. Just ask yourself, would you submit yourself to stay in a metabolic ward away from your family for 6-9 months while you eat a strict diet of measured food that may or may not contain legumes or grains. Do you think researchers are going to find 100 people to do so and who would fund that study? If the day ever comes that we see that study and the data supports grain and legume consumption I'll be all in. Until that day, I am going to go with my N=1 study that shows I am missing nothing from passing on those foods and potentially improving my health by avoiding them. I certainly feel better, have more energy, and get sick far less often.
Monday, September 23, 2013
Book review: Grain Brain
A few years back I read the book Power Up Your Brain by Dr. David Perlmutter. I was amazed at the content of that book and to say it had a major impact on the way I view human health is an understatement. One of the best things about the book is that Dr. Perlmutter has an incredible way of breaking down complex topics in to very digestible information, even for the layperson. His book was my initial introduction to epigenetics and he broke it down very well. I didn't, however, agree with the consumption of grains recommended in the book. To be fair, his program only recommended one serving per day, but even that is detrimental in my opinion. As is the case with all great thinkers and scientists, Dr. Perlmutter has both looked at the data and used his own clinical experience to modify his program...enter Grain Brain.
Before we discuss Grain Brain, I think it's important to look at Dr. Perlmutter's credentials. Dr. Perlmutter is a board certified neurologist and Fellow of the American College of Nutrition. He currently sees patients at his practice in Naples, Florida and is an Associate Professor at the University of Miami School of Medicine.
In Grain Brain, Dr. Perlmutter makes the case that consumption of grains and a high carbohydrate diet are detrimental to brain health and seem to be a primary cause for a number of neurological problems. He goes over the effects of gluten, high blood glucose, and insulin levels on brain function thoroughly. I think most people buy in to these concepts save for gluten, but one concept they will not buy in to is the health promoting effects of cholesterol on the brain and how detrimental it is to try and lower your cholesterol. He covers this in detail, and it was something he covered in depth in Power Up Your Brain as well.
The amount of research he goes over in Grain Brain is impressive. While a lot of that data is epidemiological, meaning you can't use it to draw conclusions, he uses the research in the way that it's meant to be used. He uses the data to identify the important relationships and provides the mechanisms by which the relationships may exist. It doesn't hurt that his clinical experience confirms much of his reasoning, which he points out in a few case studies throughout the book. Let's look at some of the general mechanisms he discusses in Grain Brain.
Dr. Perlmutter fingers diet as the primary cause of more or less all of the common brain diseases we are seeing today including Alzhimer's disease, Parkinson's disease, anxiety, depression, schizophrenia and more.. He describes how a high carbohydrate diet, gluten consumption, and the avoidance of dietary cholesterol are related to brain disease in great detail. The two primary mechanisms by which diet can negatively affect brain health are inflammation and free radical production. If you don't have a thorough understanding of how these processes are interrelated, this book will give it to you. The research even points to blood glucose levels in the normal range as being detrimental to brain health and he describes why very well. Let's just say that by the time you have diabetes or pre-diabetes, you have done significant damage already.
While most of the book is related to brain health, he discusses several instances where patients have resolved terrible neurological problems by removing gluten from their diet. The science has identified the vagus nerve as the conduit through which the bacteria in your gut communicate with your brain(1). If pathogenic bacteria are able to hijack the vagus nerve, bad neurological problems are sure to ensue. The vagus nerve helps control heart rate, blood pressure, and other aspects of the autonomic nervous system, specifically by calming the nervous system down, so to speak.
One thing I find very refreshing about Grain Brain is that Dr. Perlmutter squashes the notion that you can be overweight and healthy at the same time. While it is possible to be overweight and have numbers that are perfectly fine on a comprehensive metabolic panel, the effects on the brain are noticeable from the get go. Here is a quote directly from Grain Brain:
While this quote is pretty shocking, many of the findings in other studies he references match or surpass it. This is not to say that this damage is irreversible, it is completely reversible with the proper dietary and lifestyle modifications which are included in the book as an easy to follow program.
The discussion on cholesterol in Grain Brain is fantastic and should be required reading. One thing Dr. Perlmutter does in Grain Brain that he didn't in Power Up Your Brain is take on statin drugs. Given his discussion on how important cholesterol is for the brain, his take makes sense. However, he also discusses how statin drugs, although anti-inflammatory, can actually increase inflammation and free radical production.
When I started reading Grain Brain and up until about halfway through I did not buy in to his recommended carbohydrate consumption. At this point I still think his recommendations on carbohydrates are too low. His description of how glucose enters the cell is pretty simplistic and does not take in to consideration that insulin is only necessary for glucose to enter cells when at rest. However, as I read on I began to buy in a little more. When the discussion in the book began I was adamant that he was wrong, but after providing his case I'm not so sure. If you are trying to mitigate the risk of having elevated blood glucose, he may be spot on. At this point, however, my A1c and fasting blood glucose levels are in line with his recommendations. Since I have not had my fasting insulin levels checked, which he recommends, there is the potential that I am wrong.
It's funny, I really liked Power Up Your Brain. I read it as I was beginning my shift to a more Paleo way of life. What drew me to the Paleo Diet is the evolutionary approach to health. Not the mistaken notion that we are not evolved to eat certain things so much as the way we evolved has a dramatic impact on what is optimal for human health today. Dr. Perlmutter uses the same approach in Grain Brain and you don't have any of the "gotcha" scientific misrepresentations that many make about Paleo. Most of these issues were settled a few years ago but new books by hacks seem to want to rehash these issues. It's great to have people like Dr. Perlmutter on board because he is obviously a better source of information than the guy your Uncle Eddie knows who heard from another guy that gluten is only bad for celiacs. He has the scientific references and clinical experience to back up his assertions and I am thankful he invests his time in writing books to help people that aren't his patients.
The grand question is will Grain Brain make a difference? I'm a bit cynical about how big of an impact this will have. It is estimated that 90% of Americans are for the labeling of GMOs, yet somehow California is unable to pass a bill requiring the labeling of GMOs. This is because corporations have essentially unlimited funds to mislead a populace that is uninformed at best and stupid at worst. I bought and read this book on the day it was released and I will buy a few more copies for people I want to read it to help push it up the NY Times best seller list. If it gets to the top, the discussion on cholesterol will at least annoy some vegans I know.
Overall I give Grain Brain a 9 out of 10. I still think the discussion on carbohydrate metabolism is off and potatoes and low fructose fruits are probably perfectly fine to consume within a sane level of total daily carbohydrates (150g or so). Everything else in the book is great and I think most people would be healthier and happier trying his 4 week program.
Before we discuss Grain Brain, I think it's important to look at Dr. Perlmutter's credentials. Dr. Perlmutter is a board certified neurologist and Fellow of the American College of Nutrition. He currently sees patients at his practice in Naples, Florida and is an Associate Professor at the University of Miami School of Medicine.
In Grain Brain, Dr. Perlmutter makes the case that consumption of grains and a high carbohydrate diet are detrimental to brain health and seem to be a primary cause for a number of neurological problems. He goes over the effects of gluten, high blood glucose, and insulin levels on brain function thoroughly. I think most people buy in to these concepts save for gluten, but one concept they will not buy in to is the health promoting effects of cholesterol on the brain and how detrimental it is to try and lower your cholesterol. He covers this in detail, and it was something he covered in depth in Power Up Your Brain as well.
The amount of research he goes over in Grain Brain is impressive. While a lot of that data is epidemiological, meaning you can't use it to draw conclusions, he uses the research in the way that it's meant to be used. He uses the data to identify the important relationships and provides the mechanisms by which the relationships may exist. It doesn't hurt that his clinical experience confirms much of his reasoning, which he points out in a few case studies throughout the book. Let's look at some of the general mechanisms he discusses in Grain Brain.
Dr. Perlmutter fingers diet as the primary cause of more or less all of the common brain diseases we are seeing today including Alzhimer's disease, Parkinson's disease, anxiety, depression, schizophrenia and more.. He describes how a high carbohydrate diet, gluten consumption, and the avoidance of dietary cholesterol are related to brain disease in great detail. The two primary mechanisms by which diet can negatively affect brain health are inflammation and free radical production. If you don't have a thorough understanding of how these processes are interrelated, this book will give it to you. The research even points to blood glucose levels in the normal range as being detrimental to brain health and he describes why very well. Let's just say that by the time you have diabetes or pre-diabetes, you have done significant damage already.
While most of the book is related to brain health, he discusses several instances where patients have resolved terrible neurological problems by removing gluten from their diet. The science has identified the vagus nerve as the conduit through which the bacteria in your gut communicate with your brain(1). If pathogenic bacteria are able to hijack the vagus nerve, bad neurological problems are sure to ensue. The vagus nerve helps control heart rate, blood pressure, and other aspects of the autonomic nervous system, specifically by calming the nervous system down, so to speak.
One thing I find very refreshing about Grain Brain is that Dr. Perlmutter squashes the notion that you can be overweight and healthy at the same time. While it is possible to be overweight and have numbers that are perfectly fine on a comprehensive metabolic panel, the effects on the brain are noticeable from the get go. Here is a quote directly from Grain Brain:
"In a joint research project between UCLA and the University of Pittsburgh, neuroscientists examined brain images of ninety-four people in their seventies who had participated in an earlier study of cardiovascular health and cognition...What these researchers found was that the brains of obese people-defined by having a body mass index above 30-looked sixteen years older than their healthy counterparts of normal weight. And those who were overweight-defined by having a body mass index between 25 and 30-looked eight years older than their leaner counterparts."
While this quote is pretty shocking, many of the findings in other studies he references match or surpass it. This is not to say that this damage is irreversible, it is completely reversible with the proper dietary and lifestyle modifications which are included in the book as an easy to follow program.
The discussion on cholesterol in Grain Brain is fantastic and should be required reading. One thing Dr. Perlmutter does in Grain Brain that he didn't in Power Up Your Brain is take on statin drugs. Given his discussion on how important cholesterol is for the brain, his take makes sense. However, he also discusses how statin drugs, although anti-inflammatory, can actually increase inflammation and free radical production.
When I started reading Grain Brain and up until about halfway through I did not buy in to his recommended carbohydrate consumption. At this point I still think his recommendations on carbohydrates are too low. His description of how glucose enters the cell is pretty simplistic and does not take in to consideration that insulin is only necessary for glucose to enter cells when at rest. However, as I read on I began to buy in a little more. When the discussion in the book began I was adamant that he was wrong, but after providing his case I'm not so sure. If you are trying to mitigate the risk of having elevated blood glucose, he may be spot on. At this point, however, my A1c and fasting blood glucose levels are in line with his recommendations. Since I have not had my fasting insulin levels checked, which he recommends, there is the potential that I am wrong.
It's funny, I really liked Power Up Your Brain. I read it as I was beginning my shift to a more Paleo way of life. What drew me to the Paleo Diet is the evolutionary approach to health. Not the mistaken notion that we are not evolved to eat certain things so much as the way we evolved has a dramatic impact on what is optimal for human health today. Dr. Perlmutter uses the same approach in Grain Brain and you don't have any of the "gotcha" scientific misrepresentations that many make about Paleo. Most of these issues were settled a few years ago but new books by hacks seem to want to rehash these issues. It's great to have people like Dr. Perlmutter on board because he is obviously a better source of information than the guy your Uncle Eddie knows who heard from another guy that gluten is only bad for celiacs. He has the scientific references and clinical experience to back up his assertions and I am thankful he invests his time in writing books to help people that aren't his patients.
The grand question is will Grain Brain make a difference? I'm a bit cynical about how big of an impact this will have. It is estimated that 90% of Americans are for the labeling of GMOs, yet somehow California is unable to pass a bill requiring the labeling of GMOs. This is because corporations have essentially unlimited funds to mislead a populace that is uninformed at best and stupid at worst. I bought and read this book on the day it was released and I will buy a few more copies for people I want to read it to help push it up the NY Times best seller list. If it gets to the top, the discussion on cholesterol will at least annoy some vegans I know.
Overall I give Grain Brain a 9 out of 10. I still think the discussion on carbohydrate metabolism is off and potatoes and low fructose fruits are probably perfectly fine to consume within a sane level of total daily carbohydrates (150g or so). Everything else in the book is great and I think most people would be healthier and happier trying his 4 week program.
Thursday, August 29, 2013
Effects of a gluten free diet on blood lipids: A case study
Summary
A client with no history of sensitivity to gluten or abnormal blood cholesterol levels suddenly developed significant gastrointestinal pains and discomfort. Upon testing from her doctor, her blood lipids were fond to be abnormal. Removing gluten from her diet lead to an improvement in her symptoms and her blood lipids improved dramatically within 2 months. The mechanisms behind these changes are also discussed.Client History
Client is a 62 year old female who has begun to experience gastrointestinal distress over the last few months. Prior to this she has had no problems with the foods she eats. She explains that all of a sudden she started experiencing gut wrenching pain whenever she would eat.Her doctor initially put her on low dose Prilosec(20mg/day) but had to increase the dose to 60mg/day as it lost effectiveness. She was then put on Nexium with no relief, This is not surprising since Nexium converts to the same drug as Prilosec in the acidic environment of the stomach and thus has the same effect.
Other relevant history
Blood lipids were drawn and she had the following values:- Total Cholesterol: 259 mg/dL
- LDL Cholesterol: 151 mg/dL
- HDL Cholesterol: 58 mg/dL
- TC: HDL ratio: 4.5
- Triglycerides: 251 mg/dL
Client was asked which foods gave her the most trouble. She stated that beer would give her the most stomach pain followed by broccoli, pork, and anything fried. I recommended the Paleo diet to cut back on the amount of problematic proteins in her digestive tract. If she tolerated dairy she could continue eating dairy.
Client removed all grains, basically going on a gluten free diet. Her legume consumption was pretty low to begin with so she continued to keep it low. Five days after starting the diet she began to feel much better and reported not being "gassy" or having that "sick" feeling in her stomach. She ended up losing a total of 24lbs even though she didn't want to lose any weight and the arthritis in her hands improved significantly.
She has been off Nexium and Prilosec for a couple of weeks. Two months after being on the diet she had her blood lipids tested again, a total of 6 months from the previous testing. Her values are listed below.
- Total Cholesterol: 213 mg/dL
- LDL Cholesterol: 132 mg/dL
- HDL Cholesterol: 53 mg/dL
- TC: HDL ratio: 4.0
- Triglycerides: 142 mg/dL
Discussion
This client's great improvement in her blood lipid results is fairly common for people switching to this diet, and she was elated to see these improvements. While there is still more progress to be made, she has made huge strides in improving her digestion and general health. Cholesterol is a part of the immune system and when the body gets attacked, these numbers typically go up as the immune system initiates a response. Outside of this instance, the LDL numbers in a standard cholesterol panel are worthless and tend to be inaccurate since they are estimates and not directly measures.In the case of gluten, gluten causes the tight junctions between cells of the intestinal wall to dissolve, allowing undigested food particles to enter the blood circulation. This causes the immune response and could be the cause of her higher LDL numbers. Going on a gluten free diet typically improves blood cholesterol numbers in the vast majority of people, probably even better than is seen with statin drugs.
Many people believe that gluten only causes a problem for people with gluten sensitivity or celiac disease. The fact is, gluten causes the tight junctions between intestinal cells to dissolve in everybody. The difference between people with celiac disease and people without celiac disease is that the tight junctions get repaired much more quickly in people without celiac disease, but this would be dependent on teh dosage ingested and the immune system of the person. As we age our ability to deal with this becomes impaired as our immune system weakens. Digestive enzymes also decrease with age and can make things that were not previously problematic an issue. In addition, being sedentary causes food to stay in the intestines longer. Since gluten cannot be broken down by humans, the likelihood of a problem arising increases with dosage, age, and sedentary behavior. This could perhaps be the link between both age and sedentary behavior with Type 2 Diabetes and/or heart disease.
While most physicians recommend against a gluten free diet for who knows what reason, it would be in the best interests of most people to avoid or limit gluten as well as all grains and legumes. While we are most familiar with gluten, there are other storage proteins in grains and legumes that are both difficult for humans to digest and that cause an immune response. This client's improvement in the arthritis in her hands is more than likely attributed to a dampening of the immune response caused by gluten in her diet. It is interesting to point out that in her younger years she had no problems with gluten. While age and the increased sedentary time that comes with it could certainly be the causative factor, it could also be that the dosage of problematic proteins she is exposed to on a daily basis has been increased as processed foods have become more commonplace.
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