Gluten 101 · to mimic activity of opiods Intestinal Hyperpermeability is a hallmark of GS/CD Glueomorphin (and Caseomorphin) moves out of SI and is able to bind to opiod receptors

Gluten 101(or, How I learned to stop Bloating and love

Quinoa)

Michael Stadtmauer N.D., L.Ac.Champlain Wellness Center

Essex Junction

Vermont Integrative MedicineMontpelier

Gluten - What is it?

Gluten - the proteins found in cereal grains which lend an elastic

quality to dough

Gluten - What is it?

“Gluten grains” - wheat, barley, rye

wheat includes durum, semolina, spelt, kamut, malt, couscous, bulgar, triticale, einkorn, and faro

Safe grains - amaranth, arrowroot, buckwheat, corn, legume flours, mesquite flour, millet, nut flours, potato, oat, quinoa, rice, sago, sorghum, tapioca, taro, and teff

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AMR ’05

Gluten? Gliadin?

Gluten

alpha-gliandin

beta-gliadin

gamma-gliadin

omega-gliadin

and a number of other peptides including glutenins, agglutinins, Gluteomorphins, and dozens of others -

about 60 total

So, why wheat?

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Proline Content of Grains0 2 4 6 8 10 12 14 16 18 20

Rice

Buckwheat

Oats

Corn

Barley

Rye

Wheat

mg/g Proline

Non-immunogenicImmunogenic

Prolamines (grain proteins high in proline) are ineffectively digested by gastric, pancreatic

or brush border enzymes

Man: 6-8,000,000 years ago (or more)

Fire’s general use; probable start of cooking (and thus grain introduction): 40-50,000 years ago.

Neolithic Revolution - simultaneous worldwide development of plant and animal domestication: 10,000-8,000 years ago

Wheat introduction: 9,000-10,000 years ago.

Large scale farming of wheat: 5,000 years ago

Since the 1980s, almost 20 percent of the total caloric intake of U.S. adults has been bleached, refined wheat flour from 2 species

High proline content = high drought resistance = badness

Anthropologic evidence?

Up until a few decades ago - 1:5,000

Around the turn of the century - 1:250

Up until a few years ago - 1:100

Now - 15:100

Many in the field think the real number is closer to 30%

Incidence of CD/GS

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Small Intestinal Histopathology and Mortality Risk in Celiac Disease

JAMA, Sept 16, 2009,Vol 302, No. 11

350K Biopsies:

29,148 demonstrated CD (serology positive or negative; partial or complete villous atrophy)

3,719 exhibited “latent” CD (positive serology; normal villi)

13,446 showed significant Inflammatory changes consistent with reactions to gluten (no villous atrophy)

Small Intestinal Histopathology and Mortality Risk in Celiac Disease

JAMA, Sept 16, 2009,Vol 302, No. 11

0%

20%

40%

60%

80%

Celiac DiseaseLatent CD

Inflammation

Risk of Mortality (Hazard Ratio for Death)

Why?

CONCLUSIONS: During 45 years of follow-up, undiagnosed CD was associated with a nearly 4-fold increased risk of death. The prevalence of undiagnosed CD seems to have increased dramatically in the United States during the past 50 years.

Increased Prevalence and Mortality in Undiagnosed Celiac Disease

GASTROENTEROLOGY 2009

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Improved Recognition

Improved Testing

*Environmental Factors

Genetic structure of wheat

Diet

Pro-inflammatory environment

Use of anitbiotics, antacids, etc.

Why the increase?

AI Gluten ResponseBackground

HLA-DQ

Antigen Presenting cell surface receptor

Used to present antigens to T-cells

Shows some/hides some

Tissue Transglutaminase 2

Created by enterocytes to deconstruct gluten molecules

Remains bound to cleaved peptides (gliadins)

AI Gluten Response HLA-DQ Genetic Polymorphism

Identified in the major histocompatibility complex region on chromosome 6p21

CD - 90% HLA-DQ2, 10% HLA-DQ8 (100%)

However, only 4% of HLA-DQ2/8 individuals go on to develop CD

20-50% of the human population expresses DQ2

Both DQ2 and DQ8 types present several unique pocket structures that favor binding of negatively charged particles

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Ingestion of Gluten

Creation of Tissue Transglutaminase 2 to deaminate Gluten

Deamination into Gliadin peptides

AI Gluten Response

Transamidation vs. Deamidation - a key decision

AMR ’05

pH gluten concentration

Key StepGliadin peptide/tTG2 complex binds to mutated HLA-DQ (usu. 2 or 8)surface receptor

AI Gluten Response

Combination seen as non-self

T-cell mediated antibody response to both Gliadin and tTG(becoming the autoantigen)

Coeliac disease autoantibodies against tissue transglutaminase (TG2) are produced in the intestinal mucosa and the antibodies can deposit on extracellular TG2 in the small-bowel mucosa even when not measurable in serum Scandinavian Journal of Gastroenterology, 2005

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Immunogenic Gluten Response

But wait, there’s more...

In addition - cytokine driven(IL-15) mucosal inflammatory response to the presence of gliadin (in GS pop.)

This alters intraepithelial lymphocyte activity by promoting macrophage and T-cell activation

Macrophages eating Gliadin directly activates the NF-kB pathway (bad)

Seems to occur INDEPENDENT of antigen-mediated T-cell activation

NF-kappaB Inflammatory Cascade

AI Gluten Response Possibly triggered by bacteria/virus and/or Candida

Candida and some viruses (adenovirus) share genetic structures with Gliadin (great!)

Normal immune response to pathogen creates antibodies specific to that genetic sequence

Future gluten ingestion and break down generates similar peptide sequences which initiates antibody repsonse

Antibodies are refined to be specific to the gliadin sequence

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AI Gluten Response

Hyphal cell-wall component protein 1 (HWP1) of Candida and gamma-gliadin both simulate T-cell [antigen-specific] receptors and repeat similar sequences in a similar cadence, while alpha-gliadin has one of its sequences selectively deamidated by TG2, generating a metabolite with a similar sequence to HWP1. (AMR ’05)

AI Gluten Response

Common antigens in the skin and nervous system cross react with AGA and Anti-tTg

This suggests an AI component to dermatologic & neurological diseases often associated with Celiac: derm.hep, psoriasis, alopecia, epilepsy, dementia, depression, peripheral neuropathy, migraine, encephalopathy, chorea and brain stem dysfunction

Diseases Positively Associated with Gluten Sensitivity

“...CD “out of the intestine” is even more frequent than CD within the intestine” - Gastroenterology, 2004

A commonly passed around factoid is: For every GS pt with GI sx; 8 do not

The CD patient is 10X more likely to have an AI dz than the general population

Ataxia - “Implementation of a CDD can halt the disease process, although CD is commonly a missed diagnosis as gastrointestinal symptoms are only present in 13 percent of gluten-ataxic patients.” Brain, 2003

Early Brain Atrophy and Dementia

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Neuropathy - 49% of CD patient report sensory, symmetrical neuropathy

SLE

Polymyositis

Vasculitis - “White-matter lesions or calcifications of ischemic origin [in the brain] have been suggested as secondary to CD-generated vasculitis [of the BBB].” AMR’05

Carcinomas of the upper GI tract/ T and B type Lymphomas

Diseases/Conditions Positively Associated with Gluten Sensitivity

Headache/Migraine

Depression - decreased amounts of dopamine/serotonin in CSF of CD pts; might be secondary to known tendency for tryptophan deficiency

Epilepsy - 50% of drug resistant epileptics are put in permanent remission on a GF diet.

Sjogren’s Syndrome (very strong linkage) - should always try CDD


Type 1 Diabetes Very high association

Celiac patients have 3-fold increased chance of developing Type 1 (most likely severely underestimated - only looked at frank celiac disease)

60% of people screened at dx for Type 1 were found to also have Celiac

“Feeding gluten-containing foods in the first three months of life yields a four-fold greater risk of developing islet cell auto-antibodies (and potentially subsequent diabetes) than exclusive breast feeding.” JAMA 2003

Some children with celiac disease but without diabetes have high levels of islet cell antibodies that disappear on a gluten-free diet

Many review papers recommend screening for celiac disease in all patients with type 1 diabetes

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Thyroiditis -

positive auto-antibodies in 60(+)% of Celiac pts

28% of children with Celiac, age 6, had (+) Thyroid Auto-AB

Addison’s disease (70+% related to AI activity)

Gall Bladder Dysfunction - CCK deficiency common because production is centered on the microvilli


Arthritis/RA - increased amounts of tTg2 found in synovium of RA pts

Dermatitis Herpetiformis - considered to be cutaneous Celiac (autoanitgen is epidermal transglutaminase)

Osteoporosis - direct relationship between tTG levels and the severity of osteoporosis


Common deficiencies include:

B12/Folate (fatigue, peripheral neuropathy/paraesthesia)

Iron

Carnitine(fatigue)

Selenium

Vitamin A(night blindness/dry eye)

Vitamin D(osteomalacia)

Vitamin E(neuropathy)

Vitamin K(excessive bleeding)

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Urticaria

Alopecia

Schizophrenia (many studies)

Dental enamel defects

AI Hepatitis

Primary Biliary Cirrhosis

Anemia

Chronic Fatigue

Infertility & Recurrent Miscarriage

non-Hodgkin Lymphoma


So, we have:

Hematologic, rheumatologic, bone, neurological, endocrine, hepatic, dental, and cutaneous presentations and associations

Many organ and non-organ specific Autoimmune Conditions

Malignancies

THESE CAN ALL OCCUR WITH OR WITHOUT GI SYMPTOMS

AUTISMPepsin (in ST) breaks down gluten into 5 or more distinct gluteomorphins (in addition to other peptides).

Gluteomorphin - a large morphine-like peptide able to mimic activity of opiods

Intestinal Hyperpermeability is a hallmark of GS/CD

Glueomorphin (and Caseomorphin) moves out of SI and is able to bind to opiod receptors in the brain. (bad)

Possibly at play in Autism, Depression, Brain Fog, ADD

Hypo gonadal/ovarian function, Hypo-Adrenal states and Growth Hormone deficiency are all well established side effects of chronic opioid stimulation

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How to recognize the Gluten Sensitive Patient

MCV > 95 / High Homocysteine

Ferritin < 10 (Approx. 30% of chronic anemia patients found to have gluten-related intestinal changes)

Eosinophils > 3.0

Hx or FmHx of Asthma, Eczema, RA, Migraines, Hashimoto’s, SLE, IBS, Type 1 Diabetes, Celiac

Hx of loose and/or greasy stool - also usu. bloating

Inflammatory/Allergic History (miasmatic?)

Most common presenting sx prior to CD dx: Fatigue (not a GI sx) “Currently, less than half the patients diagnosed with CD present with diarrhea” - Cell. Mol. Life Sci., 2005

Assessing Gluten SensitivityBlood Tests -

IgA-AGA (most common, only 68% sensitivity for Celiac)

IgA-tTG - positive strongly correlates with total villous atrophy; best marker in children; 89% sensitivity in CD

Anti-endomysial (EMA) - 90% sensitivity in CD

Tied to villous atrophy extent

Present in 77% with total atrophy and 33% of those with partial or less,

IgG-AGA/tTG - more likely to be high in IgA deficiency

IgG AGA sensitivity - 90-100% total/ 30-40% partial

15% of diagnosed celiac patients (by biopsy) have no serologic markers

Remember - reference ranges are for identifying CD

Minimum acceptable blood work - IgG/IgA AGA+tTg

Assessing Gluten Sensitivity

Mayo Serologic reflex and/or Genetic panel

Saliva IgA-AGA - only meaningful with normal total SIgA

Stool IgA-tTG/AGA, fat content

Total sIgA - Saliva, Stool

Genetic testing for predisposing polymorphisms

New salivary markers looking at IgM+IgA AGA/tTG might be useful screening/monitoring tool

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Assessment IssueCurrent testing looks only at the alpha-gliadin 33-MER peptide

Studies suggest that only about 30% of CD pts react to only this peptide

Other peptides, including other alpha varients, gamma and omega moities and various other peptides have been determied to also cause the GS/CD response in certain individuals (in addition/as opposed to a-gliadin33)

Very little research has been done to determine which peptides have greater or lesser immunogenic potential

Cyrexlabs.com

- Salivary IgA+IgM Gliadin and tTG; and total IgA

- IgA and IgG Glutenin, Agglutinin, Gluteomorphin, a-Gliadin 17 and 33, gamma-gliadin, omega-gliadin,

tTG

- IgA and IgG cross reactive foods panel

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Issues - Cross Reactivity

Many grains share similar antigenic structures, as do other proteins.

A mucosal inflammatory response similar to that elicited by gluten was produced by [Cow’s milk] protein in about 50% of the patients with coeliac disease. Casein, in particular, seems to be involved in this reaction. Clin Exp Immunol. 2007

Up to 30% of people have measurable signs of CD on a CDD

Cross reactivity has been demonstrated in:

sesame, millet, sorghum, buckwheat, tapioca, oat, rice, corn, potato, coffee

Treating Gluten Sensitivity/Celiac Disease

Celiac Disease Diet (not enough)Mucosal Recovery and Mortality in Adults with Celiac Disease After Treatment With a Gluten-free Diet - Am J Gastroenterol. 2011

82% had clinical response to CDDComplete mucosal recovery occurred in only 34% of CD patients on a CDD at 2 yearsRecovery at 5 years was 66%Recovery in children is 95% at 2 yearsTotal villus atrophy at dx was strongly associated with non-recovery despite diet.Clinical response does not correlate with mucosal recovery.Correlation between all-cause mortality and mucosal recovery


So, we have to do more...

Fish Oil

L-Glutamine/N-acetyl Glucosamine

Many recent papers point to the role of Intestinal Hyperpermeability (almost an absolute in CD/GS) in the etiology of AI dz - the correlation seems very tight

Probiotics

Saccharomyces boulardii - promotes sIgA

Zinc - “Celiac disease is refractive to dietary therapy if an underlying zinc deficiency is present.” (TNM)

Pancreatic Enzymes - especially in first month or two

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Eliminate Dairy - at least for the first year.

Lactase production occurs on the microvilli

Assess Gut Flora

Assess Gut pH - acidic environments strongly drive deamidation

Investigate other Food Intolerances

Limit Vitamin A? - Nature 02/11 - RA significantly up-regulated inflammatory cytokine activity in CD mouse model.

Educate


New kid on the block...

Dipeptidyl Peptidase IV (DPP-IV) is an enzyme specific to high-proline peptides.

Thought to help by providing break-down of the gluten protein to sub-gliadin peptides

Theoretically, this would negate/reduce the need for tTG2 and help curb the AI response

Treatment Summary

Stop throwing fuel on the fire

Look for pathogens

Create a proper intestinal milieu

Stimulate healing and repair

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Issues-Labeling

About 50% of all drugs list “starch” as a filler ingredient - almost none state the source

The current FDA draft rules allow up to 20ppm gluten in food labeled “gluten-free”

Average American eats 4.7 lbs. of food/day (USDA) ≈ 42 mg gluten (potentially)

Up to six percent of foods labeled “gluten-free” in North America contain more than 300 mg gliadin/kg of product (300ppm)

Most countries follow the WHO/UN guidelines for gluten-free foods which allow for .3% of the protein content to be gluten.

= 300 mg/day for average American > threshold established in some studies [0-50]

Issues - Compliance

#1 Reason for non-responsiveness to CDD:

Gluten exposure

Unknown Dietary exposure

Misc. Exposure:Make-up Play dough Stamps Pet foodLipstick Paints Envelopes Baby powerLip balm Toothpaste Suntan lotion Bath salts Shampoo Moisturizer

GF TidbitsWhen GS individuals have wheat reintroduced to their diets, times-to-relapse vary enormously among individuals, ranging from hours to months, or even years

Over 50% will not respond until 3-4 weeks.

A single exposure can produce inflammatory/antibody responses for the next 3 months

CD occurs in about 15% of the offspring of CD patients

When one twin is positive for CD, only 70-80% will both be positive.

Some research has shown that early introduction of cow’s milk is a significant etiological factor in the genesis of CD.

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GF Tidbits…every time the disease is clinically diagnosed in an adult, that person has for decades had disease in a latent or silent stage... N Engl J Med 2003

Occult coeliac disease seems to start in childhood, even in those who are subsequently diagnosed as adults. BMJ 2004

Research has clearly shown that introducing gluten while still nursing imparts significant protection against the development of CD

But just as clearly - not before 6 months old

Many studies have demonstrated that gliadin-mediated mucosal inflammatory changes readily occur in the ilium and rectum

GF Tidbits

In US

Pts have sxs an average of 11 years before dx

More than a third consult 2 or more GI docs before dx

Most common previous dxs: anemia, stress, IBS

Gluten causes gastrointestinal symptoms in subjects without celiac disease

Am J Gastroenterol. 2011

IBS patients self-reporting success on CDD

DB/PC Gluten/Non-gluten groups

Within 1 week on gluten, patients reported significantly worse pain, bloating, stool changes, fatigue

Whatchu talkin ‘bout, Willis?

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Despite knowing who to look at, there were no markers to identify who was or was not on a CDD

In these patients (non-Celiac, Gluten Responders), AGA, tTG, hs-CRP, fecal lactoferrin were all normal.



CONCLUSIONS: "Non-celiac gluten intolerance" may exist, but no clues to the mechanism were elucidated.

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Documents

Gluten 101 · to mimic activity of opiods Intestinal Hyperpermeability is a hallmark of GS/CD Glueomorphin (and Caseomorphin) moves out of SI and is able to bind to opiod receptors