Now that you know you’re sensitive to gluten you’re very carefully avoiding all the wheat bread, bagels, cookies and cakes. You’ve stopped eating oatmeal for breakfast (you know about the contamination of oats) and you watch those protein bars for all signs of glutinous grains. You’re aware that fried chicken and breaded anything is also a problem and you’ve realized the hidden danger of sauces and things like meat loaf.
So where might you get tripped up? The biggest problem we run into with patients is with certain ethnic foods that cook with soy sauce. It’s just not “obvious” that soy sauce has wheat in it. When you cook at home you can definitely enjoy cooking with wheat-free soy sauce (usually known as Tamari) but Chinese and Japanese food very often contains soy sauce and if the sauce is brown you probably just got a nice hit from gluten.
The cautionary tale here is keep learning about food and how it’s prepared. As someone who enjoys cooking I know how many things are prepared so I rarely get fooled.
It you’re sensitive to gluten ANY is too much – way too much!
I hope this helps!
To your good health,
Dr Vikki Petersen
Friday, November 14, 2008
Monday, November 03, 2008
Case Study
Here is another amazing case study about missing gluten sensitivity in a young woman who's been suffering needlessly. A simple screening for gluten would have prevented a lot of unecessary pain. This case exemplifies why we wrote our book. Hopefully increasing awareness will diminish these types of cases. “The Gluten Effect” is being published early January 2009. Stay tuned!
Recently a young lady age 19 came to see us, referred from a local celiac website. Her story epitomizes why we wrote our book and the medical community’s shameful lack of understanding of gluten and how it can affect the human body.
This patient, at the tender age of 16, began experiencing rather severe neurological problems. She had tremors in her hands and trouble walking due to pain and weakness. She suffered from brain fog and very poor concentration. When her joint pains got too severe she had to get a wheelchair. She also developed hearing problems.
While visiting a neurologist the patient’s mother asked the doctor if gluten or celiac disease could be a possible component in her daughter’s condition. Being a good mother she had done some research and wanted the doctor’s opinion. She had concurrently brought her daughter to a gastroenterologist and had requested a test for celiac disease but at the time of the conversation with the neurologist she had not yet received the results. The neurologist assured her that there was absolutely no way her symptoms could possibly be associated with gluten and proceeded to discuss multiple sclerosis and other possible neurological problems as the likely diagnosis.
Two days later her celiac test came back… positive. Upon removing gluten from her diet her symptoms improved considerably. But, as is often the case, simply removing gluten and doing nothing else is not sufficient.
What are our plans to restore her health? Glad you asked!
First we’re going to rule out any hidden infections lurking in her intestines. Remove gluten was a great first start to improving her health and she did notice some improvement. But what an infectious organism will do is prevent the intestine from healing to a large degree. This lack of healing and inflammation will cause a malabsorption of nutrients to persist which can in turn prevent healing in addition to compromising one’s immune system.
Second it is critical to heal the intestines so that they can effectively provide the function for which they are designed – namely turning food into fuel which then nourishes all the cells of the body. This young lady had very severe symptoms at quite a young age which tells us that her body’s recuperative abilities are very stressed and compromised and she likely suffers from a “leaky gut”. Therefore evaluating the status and integrity of the intestine and using nutrients, probiotics, etc to heal it will be very important.
Next we need to evaluate the status of her adrenal glands. This is the stress gland which is responsible for making many hormones, maintaining joint integrity, controlling inflammation and pain plus much, much more. Her chronic pain for many years has created a great strain on her adrenal glands so their function must be evaluated and supported.
And lastly there may very well be some genetic factors which have predisposed her to developing these various symptoms. Genetics can create the predisposition but targeted nutrition can offset that predisposition such that the patient can regain their good health.
In summary, there are still many avenues to address to restore this young lady’s health and I thought it might be interesting to talk you through our procedures which are producing excellent results in our patients.
The frustration of so few people being properly diagnosed who have gluten sensitivity is compounded by the fact that even when they are diagnosed the necessary follow-up and supportive care is not done.
The good news is that help is available.
To your good health,
Dr Vikki Petersen
Recently a young lady age 19 came to see us, referred from a local celiac website. Her story epitomizes why we wrote our book and the medical community’s shameful lack of understanding of gluten and how it can affect the human body.
This patient, at the tender age of 16, began experiencing rather severe neurological problems. She had tremors in her hands and trouble walking due to pain and weakness. She suffered from brain fog and very poor concentration. When her joint pains got too severe she had to get a wheelchair. She also developed hearing problems.
While visiting a neurologist the patient’s mother asked the doctor if gluten or celiac disease could be a possible component in her daughter’s condition. Being a good mother she had done some research and wanted the doctor’s opinion. She had concurrently brought her daughter to a gastroenterologist and had requested a test for celiac disease but at the time of the conversation with the neurologist she had not yet received the results. The neurologist assured her that there was absolutely no way her symptoms could possibly be associated with gluten and proceeded to discuss multiple sclerosis and other possible neurological problems as the likely diagnosis.
Two days later her celiac test came back… positive. Upon removing gluten from her diet her symptoms improved considerably. But, as is often the case, simply removing gluten and doing nothing else is not sufficient.
What are our plans to restore her health? Glad you asked!
First we’re going to rule out any hidden infections lurking in her intestines. Remove gluten was a great first start to improving her health and she did notice some improvement. But what an infectious organism will do is prevent the intestine from healing to a large degree. This lack of healing and inflammation will cause a malabsorption of nutrients to persist which can in turn prevent healing in addition to compromising one’s immune system.
Second it is critical to heal the intestines so that they can effectively provide the function for which they are designed – namely turning food into fuel which then nourishes all the cells of the body. This young lady had very severe symptoms at quite a young age which tells us that her body’s recuperative abilities are very stressed and compromised and she likely suffers from a “leaky gut”. Therefore evaluating the status and integrity of the intestine and using nutrients, probiotics, etc to heal it will be very important.
Next we need to evaluate the status of her adrenal glands. This is the stress gland which is responsible for making many hormones, maintaining joint integrity, controlling inflammation and pain plus much, much more. Her chronic pain for many years has created a great strain on her adrenal glands so their function must be evaluated and supported.
And lastly there may very well be some genetic factors which have predisposed her to developing these various symptoms. Genetics can create the predisposition but targeted nutrition can offset that predisposition such that the patient can regain their good health.
In summary, there are still many avenues to address to restore this young lady’s health and I thought it might be interesting to talk you through our procedures which are producing excellent results in our patients.
The frustration of so few people being properly diagnosed who have gluten sensitivity is compounded by the fact that even when they are diagnosed the necessary follow-up and supportive care is not done.
The good news is that help is available.
To your good health,
Dr Vikki Petersen
Thursday, October 09, 2008
Tired? Sleepless Nights?
Is exhaustion disrupting your work and life?
Come get the answers to these questions:
- How much sleep do you actually need?
- Is less sleep associated with disease and aging?
- How can you handle poor sleep naturally.
- How is sleep associated with weight gain?
- Why do you wake up in the middle of the night?
- How what and when you eat affect sleep quality?
Join us Wednesday, October 22nd at 7 p.m.
HealthNOW Medical Center
Call 408-733-0400 to reserve your seat.
It is FREE!
Bring your family and friends!
HealthNOW Medical Center
Call 408-733-0400 to reserve your seat.
It is FREE!
Bring your family and friends!
Tuesday, August 26, 2008
Enterolab
A reader writes: “Anne mentions Enterolab helping her confirm her gluten sensitivity. Can you please comment on the different gluten sensitivity related tests (e.g. stool test) that are offered by Enterolab (www.enterolab.com)? How much more accurate are they compared to the saliva test and the modified elimination diet that your clinic uses? Why does your clinic not use any of these tests to determine gluten sensitivity?”
Actually, here at HealthNOW we utilize many different testing methods to help a patient determine if they are sensitive to gluten. Please see below for further data:
Common Tests to Diagnose Gluten Sensitivity
Blood Testing
Genetic Blood Tests - Genetic blood studies assess an individual’s capacity to carry one of the HLA genes that is associated with gluten sensitivity. Studies support that 90 percent of patients with gluten sensitivity carry the HLA DQ2 gene, and others may carry the HLA DQ8 gene commonly.
These tests are not performed as commonly now as other antibody tests which are more accurate and have thus replaced them. However, genetic screens can be helpful in individuals who are at risk of having gluten sensitivity. For example, in relatives and children of gluten sensitive individuals with negative blood antibody tests, HLA patterns can indicate future risk. If both HLA DQ2 and HLA DQ8 are absent, the risk of being gluten intolerant is minimal and it would negate the need for future testing for the individual. If positive, continued periodic screening and a gluten-free diet would be indicated.
The other area of benefit in genetic testing is for children. The ease of testing by simply swabbing the inside of the mouth makes this less invasive for a small child. This may be a reasonable screening test in children at risk for gluten sensitivity.
Anti-Gliadin Antibodies - Gliadin is the protein component of gluten that triggers the immune reactions in sensitive people, and therefore many people with gluten sensitivity have antibodies to this protein. Testing for anti-gliadin antibodies (AGA) is a simple blood test, but studies have shown that it is less sensitive for detecting Celiac disease compared to other antibodies which will be discussed later. The confusion, as stated earlier, is that the ability of AGA to detect gluten intolerance has been defined in conjunction with a positive intestinal biopsy. While this may be a standard for Celiac disease, we now know that this is an inaccurate standard for gluten sensitivity. In fact, AGA may be the best current diagnostic test when considering all gluten related disorders.
In testing for AGA, antibodies of both the IgG and IgA classes are checked since low total levels of IgA may be present. If a person has low total IgA levels, antibody tests for IgA may be falsely negative.
Anti-Endomysial Antibodies - Unlike Anti-Gliadin Antibodies, Anti-Endomysial Antibodies (EM antibodies) are auto-antibodies. What do we mean by this? Gliadin is a gluten protein so therefore when the immune system attacks it, is not attacking “self” tissues but instead a foreign food protein. In contrast, as gliadin is absorbed through the intestinal lining, it attaches to the smooth muscle cells of the intestinal wall. EM antibodies are directed against proteins of these smooth muscle cells, and therefore EM antibodies are directed against “self” tissue. This defines them as auto-antibodies.
Because EM antibodies attack the smooth muscle of the small intestine, these antibodies correlate better with damage to the intestine wall. Studies have supported an accuracy rate of approximately 90 percent for Celiac disease. Actually in one study, EM antibodies were present in 100 percent of individuals when total villous atrophy was present. However, EM antibodies are ineffective in detecting individuals with silent or subclinical gluten sensitivity. If minor involvement of the intestinal lining occurs or if no intestinal involvement is present, EM antibodies are much less accurate.
As with Anti-Gliadin Antibodies, EM antibody testing should evaluate IgG and IgA forms of antibodies for the same reason as described above. If a gluten sensitive patient is IgA deficient, IgA EM antibodies may be falsely negative even for Celiac disease.
Anti-tissue Transglutaminase Antibodies - Similar to Anti-Endomysial Antibodies, Anti-tissue Transglutaminase Antibodies (tTG antibodies) are also auto-antibodies directed against “self” tissue. After gliadin crosses the intestinal lining, a special enzyme called tissue transglutaminase binds to gliadin and takes off a portion of the protein. This portion is called glutamine. tTG antibodies are antibodies that are directed against the complex of gliadin attached to tissue transglutaminase. Because tissue transglutaminase is a “self” enzyme, tTG antibodies are also auto-antibodies.
Also like Anti-Endomysial Antibodies, tTG antibodies are 90 percent accurate in Celiac disease 5 because they represent immune system attack at the level of the intestinal lining. Gluten sensitivity that involves minor intestinal injury or no villous atrophy will be less likely detected by tTG antibodies. Therefore, tTG antibodies correlate best with villous atrophy as several studies have supported, and a negative tTG antibody test (or EM antibody test for that matter) does not rule out gluten sensitivity when intestinal involvement is minimal or absent.
While some researchers support tTG antibodies as being a sensitive test for identifying Celiac disease, it is less sensitive for gluten sensitivity in a broader sense. This makes logical sense given the location of where this enzyme acts on gliadin. Disorders related to gluten sensitivity that do not involve the intestinal tract would be unlikely to trigger tTG antibody response from the immune system.
Deaminated Gliadin Antibodies - After tissue transglutaminase detaches the glutamine protein from gliadin, the remaining gliadin protein is termed a “deaminated” gliadin. The immune system can make specific antibodies against several different parts of the gliadin protein, and a deaminated gliadin can provoke different antibodies to be produced compared to an intact gliadin protein. As a result, newer antibody tests detect antibodies made against deaminated gliadin selectively. In studies looking again at Celiac disease patients only, deaminated gliadin antibodies had an accuracy rate of approximately 85 percent making it comparable to EMA and tTG antibody tests.
The ability of deaminated gliadin antibodies to detect gluten sensitivity outside of Celiac disease is not known. In Celiac disease patients with IgA deficiency, the IgG test for deaminated gliadin antibodies was as effective as tTG tests. Because testing for deaminated gliadin antibodies offers little advantage over tTG and EMA antibody tests, it is usually not commonly ordered. It may be an effective tool in screening for gluten sensitivity but to date these studies have not been performed.
Total Serum IgA Level - Low total levels of IgA antibodies are rarely found in the normal population with one out of every six hundred people having this condition, but in gluten sensitivity, low IgA levels are more common. This reflects the increased IgA antibody production in the intestine to fight off gluten as it attempts to enter our bodies. If a low level of IgA is present, then certainly IgG varieties of the antibody tests described above will be more accurate in diagnosing gluten related conditions. In general, total IgA levels are not ordered often since IgG antibody tests are usually ordered concurrently. Therefore, defining a low IgA level adds little information in making a diagnosis. There is a general theory however that a lower IgA level suggests greater inflammation of the intestinal lining and greater chronicity of disease. A low IgA level may provide some insight into duration of disease.
Saliva testing
Saliva Antibody Testing - While serum antibody testing has been shown in some studies to be more accurate than saliva testing in gluten sensitive patients, IgM and IgA antibodies are also made in the saliva allowing a less invasive way of screening for gluten sensitivity. The difficulty is that these saliva tests have yet to be tested against patient’s response to a gluten free diet in large populations. The saliva tests are therefore not as widely accepted in the medical community. However, our clinical experience shows the tests to be very accurate when correlated with clinical changes that occur with a gluten-free diet. There are research projects currently underway to show the validity of saliva testing, and it is our belief that saliva testing in the future may become one of the best screening tests because of its ease and low cost.
Fecal Testing
Fecal Anti-Gliadin Antibodies - As you may recall, the immune system begins its line of defense against gluten in sensitive individuals at the intestinal lining by producing IgA antibodies. In keeping with this information, it is predicted that IgA levels against gliadin in the stool may be a more sensitive reflection of gluten intolerance compared to blood testing. One researcher has conducted extensive research in this area and reports statistics that 100 percent of Celiac disease patients have fecal Anti-Gliadin Antibodies (fAGA) and over 70 percent of those with gluten sensitivity have fAGA. This research has yet to be independently duplicated by other research studies but if the current research holds true, then someday fecal testing may prove to be one of the best and most reliable methods for testing for gluten sensitivity.
Scopes and Biopsies
Upper Esophagogastroduodenoscopy (EGD) - Despite the advent of less invasive blood, saliva and fecal tests, there are several clinicians that feel a small intestinal biopsy is required before instituting a gluten free diet. These clinicians may not have distinguished between Celiac disease and the bigger category of disease that falls under gluten sensitivity, or they may not be aware of the broad effects that gluten can have on our health. As research supports, Celiac disease represents a fraction of all gluten related health disorders. Additionally, there exists a misconception by a few that a gluten free diet is a major inconvenience as a treatment. This lends some clinicians to support biopsies for “proof” before committing one to what they feel is a very restrictive diet. In actuality, being gluten free is quite easy and very healthy. Better understanding of this among clinicians may also change an insistence on small intestinal biopsies.
EGD is administered to a person while they are in a lightly sedated state. A flexible tube with a light and a tiny camera at the end of the scope is slowly inserted through the mouth and navigated through the esophagus, the stomach, and into the upper portion of the small intestine. The small intestine is vast, and EGD only assesses the first five feet or so of the small intestine. This causes some significant limitation in terms of finding pathology in many cases.
In addition to directly visualizing the intestinal lining, EGD can biopsy portions of the intestinal wall for evaluation. Small “pinchers” take little pieces of tissue that can be examined later under a microscope. Specifically in gluten disorders, findings sought include villous atrophy and inflammation of the intestinal wall. Unfortunately, contrary to some people’s beliefs, a negative biopsy does not rule out gluten sensitivity. In fact, it does not even rule out Celiac disease 100 percent of the time. Because EGD samples only a portion of the small intestine, and because the area of intestinal lining chosen for biopsy may not be involved with inflammation, a biopsy can be falsely negative even when Celiac disease is present. The small intestine is 21 feet long with the surface area the size of a tennis court. With that picture in mind one can appreciate that a biopsy even in Celiac disease may fail to make an accurate diagnosis.
Secondary Tests
We do want to stress that having gluten sensitivity for a prolonged time can cause secondary health problems. Chronic stimulation and attack of the immune system makes the body vulnerable to other infections which we see commonly. Evaluating for the presence of parasites, amoebas, bacteria, etc is critical for not only regaining one’s health but for the successful healing of a damaged small intestine. Also nutritional deficiencies as a result of intestinal inflammation are significant problems for many with gluten sensitivity. Calcium, magnesium, Vitamin B12 and Iron are just a few of these commonly seen. Concurrent food allergies, such as lactose intolerance, can also develop secondary to being sensitive to gluten. Lastly, adrenal exhaustion must be considered in many patients with longstanding gluten related disorders as we discussed in the chapter on adrenal disorders.
The most common scenario we see involves a patient suffering many years with gluten sensitivity. We are able to make the diagnosis and proceed to eliminate gluten from the diet. Improvements occur, but all symptoms are not completely resolved. Secondary testing then reveals one or more of these other health problems that require further attention until complete restoration of health can be achieved.
Our Approach is to Identify the Root Cause
We have helped numerous people who have suffered for years with gluten sensitivity but had not been accurately diagnosed previously. Many of our success stories utilizing the HealthNOW Method are included in our upcoming book. The bottom line is that there is no perfect blood test or biopsy protocol to define 100 percent of those with gluten sensitivity. At least not yet. Therefore, you have to consider the limitations of these tests as you undergo evaluation.
Our approach to a person in poor health is first to identify the symptoms and to which bodily system these symptoms are related. The next step is to find what stressor may be affecting this bodily system and remove it. Stressors can include toxins, foods, infections, malnutrition, physical stress, emotional stress, and others. Because our bodies are so resilient, once we eliminate the stressor our bodies have an amazing ability to heal over time.
Our algorithm for diagnostic testing in gluten sensitivity is to screen everyone. It is our belief that gluten sensitivity testing should be part of an annual health examination. Given the impact this dietary substance can have on multiple areas of the body, why shouldn’t we screen for gluten sensitivity? As a means of prevention of further illnesses and a lower quality of life, the benefits in costs alone would outweigh the costs of screening.
How do we test everyone? Generally, everyone is tested with a saliva and blood evaluation of Anti-Gliadin Antibodies (IgG and IgA) as well as Anti-tissue Transglutaminase Antibodies (IgG and IgA). In small children we will consider an oral swab for genetic screening for HLA patterns. At the same time, we place all patients on a Modified Elimination Diet (MED) for 10 days that eliminates gluten and other common food allergies such as cow’s milk, corn and soy products, while invoking a good balance of healthy foods such as lean protein, vegetables and fruits. By assessing the response to the MED and the results of the diagnostic tests, we will receive a highly accurate assessment of gluten intolerance.
For us, the gold standard for diagnosing gluten sensitivity is not an intestinal biopsy or a blood test. It is a beneficial response to elimination of gluten in the diet. We have hundreds of patients that have benefited from this diagnostic approach of getting to the root cause.
To your good health,
Actually, here at HealthNOW we utilize many different testing methods to help a patient determine if they are sensitive to gluten. Please see below for further data:
Common Tests to Diagnose Gluten Sensitivity
Blood Testing
Genetic Blood Tests - Genetic blood studies assess an individual’s capacity to carry one of the HLA genes that is associated with gluten sensitivity. Studies support that 90 percent of patients with gluten sensitivity carry the HLA DQ2 gene, and others may carry the HLA DQ8 gene commonly.
These tests are not performed as commonly now as other antibody tests which are more accurate and have thus replaced them. However, genetic screens can be helpful in individuals who are at risk of having gluten sensitivity. For example, in relatives and children of gluten sensitive individuals with negative blood antibody tests, HLA patterns can indicate future risk. If both HLA DQ2 and HLA DQ8 are absent, the risk of being gluten intolerant is minimal and it would negate the need for future testing for the individual. If positive, continued periodic screening and a gluten-free diet would be indicated.
The other area of benefit in genetic testing is for children. The ease of testing by simply swabbing the inside of the mouth makes this less invasive for a small child. This may be a reasonable screening test in children at risk for gluten sensitivity.
Anti-Gliadin Antibodies - Gliadin is the protein component of gluten that triggers the immune reactions in sensitive people, and therefore many people with gluten sensitivity have antibodies to this protein. Testing for anti-gliadin antibodies (AGA) is a simple blood test, but studies have shown that it is less sensitive for detecting Celiac disease compared to other antibodies which will be discussed later. The confusion, as stated earlier, is that the ability of AGA to detect gluten intolerance has been defined in conjunction with a positive intestinal biopsy. While this may be a standard for Celiac disease, we now know that this is an inaccurate standard for gluten sensitivity. In fact, AGA may be the best current diagnostic test when considering all gluten related disorders.
In testing for AGA, antibodies of both the IgG and IgA classes are checked since low total levels of IgA may be present. If a person has low total IgA levels, antibody tests for IgA may be falsely negative.
Anti-Endomysial Antibodies - Unlike Anti-Gliadin Antibodies, Anti-Endomysial Antibodies (EM antibodies) are auto-antibodies. What do we mean by this? Gliadin is a gluten protein so therefore when the immune system attacks it, is not attacking “self” tissues but instead a foreign food protein. In contrast, as gliadin is absorbed through the intestinal lining, it attaches to the smooth muscle cells of the intestinal wall. EM antibodies are directed against proteins of these smooth muscle cells, and therefore EM antibodies are directed against “self” tissue. This defines them as auto-antibodies.
Because EM antibodies attack the smooth muscle of the small intestine, these antibodies correlate better with damage to the intestine wall. Studies have supported an accuracy rate of approximately 90 percent for Celiac disease. Actually in one study, EM antibodies were present in 100 percent of individuals when total villous atrophy was present. However, EM antibodies are ineffective in detecting individuals with silent or subclinical gluten sensitivity. If minor involvement of the intestinal lining occurs or if no intestinal involvement is present, EM antibodies are much less accurate.
As with Anti-Gliadin Antibodies, EM antibody testing should evaluate IgG and IgA forms of antibodies for the same reason as described above. If a gluten sensitive patient is IgA deficient, IgA EM antibodies may be falsely negative even for Celiac disease.
Anti-tissue Transglutaminase Antibodies - Similar to Anti-Endomysial Antibodies, Anti-tissue Transglutaminase Antibodies (tTG antibodies) are also auto-antibodies directed against “self” tissue. After gliadin crosses the intestinal lining, a special enzyme called tissue transglutaminase binds to gliadin and takes off a portion of the protein. This portion is called glutamine. tTG antibodies are antibodies that are directed against the complex of gliadin attached to tissue transglutaminase. Because tissue transglutaminase is a “self” enzyme, tTG antibodies are also auto-antibodies.
Also like Anti-Endomysial Antibodies, tTG antibodies are 90 percent accurate in Celiac disease 5 because they represent immune system attack at the level of the intestinal lining. Gluten sensitivity that involves minor intestinal injury or no villous atrophy will be less likely detected by tTG antibodies. Therefore, tTG antibodies correlate best with villous atrophy as several studies have supported, and a negative tTG antibody test (or EM antibody test for that matter) does not rule out gluten sensitivity when intestinal involvement is minimal or absent.
While some researchers support tTG antibodies as being a sensitive test for identifying Celiac disease, it is less sensitive for gluten sensitivity in a broader sense. This makes logical sense given the location of where this enzyme acts on gliadin. Disorders related to gluten sensitivity that do not involve the intestinal tract would be unlikely to trigger tTG antibody response from the immune system.
Deaminated Gliadin Antibodies - After tissue transglutaminase detaches the glutamine protein from gliadin, the remaining gliadin protein is termed a “deaminated” gliadin. The immune system can make specific antibodies against several different parts of the gliadin protein, and a deaminated gliadin can provoke different antibodies to be produced compared to an intact gliadin protein. As a result, newer antibody tests detect antibodies made against deaminated gliadin selectively. In studies looking again at Celiac disease patients only, deaminated gliadin antibodies had an accuracy rate of approximately 85 percent making it comparable to EMA and tTG antibody tests.
The ability of deaminated gliadin antibodies to detect gluten sensitivity outside of Celiac disease is not known. In Celiac disease patients with IgA deficiency, the IgG test for deaminated gliadin antibodies was as effective as tTG tests. Because testing for deaminated gliadin antibodies offers little advantage over tTG and EMA antibody tests, it is usually not commonly ordered. It may be an effective tool in screening for gluten sensitivity but to date these studies have not been performed.
Total Serum IgA Level - Low total levels of IgA antibodies are rarely found in the normal population with one out of every six hundred people having this condition, but in gluten sensitivity, low IgA levels are more common. This reflects the increased IgA antibody production in the intestine to fight off gluten as it attempts to enter our bodies. If a low level of IgA is present, then certainly IgG varieties of the antibody tests described above will be more accurate in diagnosing gluten related conditions. In general, total IgA levels are not ordered often since IgG antibody tests are usually ordered concurrently. Therefore, defining a low IgA level adds little information in making a diagnosis. There is a general theory however that a lower IgA level suggests greater inflammation of the intestinal lining and greater chronicity of disease. A low IgA level may provide some insight into duration of disease.
Saliva testing
Saliva Antibody Testing - While serum antibody testing has been shown in some studies to be more accurate than saliva testing in gluten sensitive patients, IgM and IgA antibodies are also made in the saliva allowing a less invasive way of screening for gluten sensitivity. The difficulty is that these saliva tests have yet to be tested against patient’s response to a gluten free diet in large populations. The saliva tests are therefore not as widely accepted in the medical community. However, our clinical experience shows the tests to be very accurate when correlated with clinical changes that occur with a gluten-free diet. There are research projects currently underway to show the validity of saliva testing, and it is our belief that saliva testing in the future may become one of the best screening tests because of its ease and low cost.
Fecal Testing
Fecal Anti-Gliadin Antibodies - As you may recall, the immune system begins its line of defense against gluten in sensitive individuals at the intestinal lining by producing IgA antibodies. In keeping with this information, it is predicted that IgA levels against gliadin in the stool may be a more sensitive reflection of gluten intolerance compared to blood testing. One researcher has conducted extensive research in this area and reports statistics that 100 percent of Celiac disease patients have fecal Anti-Gliadin Antibodies (fAGA) and over 70 percent of those with gluten sensitivity have fAGA. This research has yet to be independently duplicated by other research studies but if the current research holds true, then someday fecal testing may prove to be one of the best and most reliable methods for testing for gluten sensitivity.
Scopes and Biopsies
Upper Esophagogastroduodenoscopy (EGD) - Despite the advent of less invasive blood, saliva and fecal tests, there are several clinicians that feel a small intestinal biopsy is required before instituting a gluten free diet. These clinicians may not have distinguished between Celiac disease and the bigger category of disease that falls under gluten sensitivity, or they may not be aware of the broad effects that gluten can have on our health. As research supports, Celiac disease represents a fraction of all gluten related health disorders. Additionally, there exists a misconception by a few that a gluten free diet is a major inconvenience as a treatment. This lends some clinicians to support biopsies for “proof” before committing one to what they feel is a very restrictive diet. In actuality, being gluten free is quite easy and very healthy. Better understanding of this among clinicians may also change an insistence on small intestinal biopsies.
EGD is administered to a person while they are in a lightly sedated state. A flexible tube with a light and a tiny camera at the end of the scope is slowly inserted through the mouth and navigated through the esophagus, the stomach, and into the upper portion of the small intestine. The small intestine is vast, and EGD only assesses the first five feet or so of the small intestine. This causes some significant limitation in terms of finding pathology in many cases.
In addition to directly visualizing the intestinal lining, EGD can biopsy portions of the intestinal wall for evaluation. Small “pinchers” take little pieces of tissue that can be examined later under a microscope. Specifically in gluten disorders, findings sought include villous atrophy and inflammation of the intestinal wall. Unfortunately, contrary to some people’s beliefs, a negative biopsy does not rule out gluten sensitivity. In fact, it does not even rule out Celiac disease 100 percent of the time. Because EGD samples only a portion of the small intestine, and because the area of intestinal lining chosen for biopsy may not be involved with inflammation, a biopsy can be falsely negative even when Celiac disease is present. The small intestine is 21 feet long with the surface area the size of a tennis court. With that picture in mind one can appreciate that a biopsy even in Celiac disease may fail to make an accurate diagnosis.
Secondary Tests
We do want to stress that having gluten sensitivity for a prolonged time can cause secondary health problems. Chronic stimulation and attack of the immune system makes the body vulnerable to other infections which we see commonly. Evaluating for the presence of parasites, amoebas, bacteria, etc is critical for not only regaining one’s health but for the successful healing of a damaged small intestine. Also nutritional deficiencies as a result of intestinal inflammation are significant problems for many with gluten sensitivity. Calcium, magnesium, Vitamin B12 and Iron are just a few of these commonly seen. Concurrent food allergies, such as lactose intolerance, can also develop secondary to being sensitive to gluten. Lastly, adrenal exhaustion must be considered in many patients with longstanding gluten related disorders as we discussed in the chapter on adrenal disorders.
The most common scenario we see involves a patient suffering many years with gluten sensitivity. We are able to make the diagnosis and proceed to eliminate gluten from the diet. Improvements occur, but all symptoms are not completely resolved. Secondary testing then reveals one or more of these other health problems that require further attention until complete restoration of health can be achieved.
Our Approach is to Identify the Root Cause
We have helped numerous people who have suffered for years with gluten sensitivity but had not been accurately diagnosed previously. Many of our success stories utilizing the HealthNOW Method are included in our upcoming book. The bottom line is that there is no perfect blood test or biopsy protocol to define 100 percent of those with gluten sensitivity. At least not yet. Therefore, you have to consider the limitations of these tests as you undergo evaluation.
Our approach to a person in poor health is first to identify the symptoms and to which bodily system these symptoms are related. The next step is to find what stressor may be affecting this bodily system and remove it. Stressors can include toxins, foods, infections, malnutrition, physical stress, emotional stress, and others. Because our bodies are so resilient, once we eliminate the stressor our bodies have an amazing ability to heal over time.
Our algorithm for diagnostic testing in gluten sensitivity is to screen everyone. It is our belief that gluten sensitivity testing should be part of an annual health examination. Given the impact this dietary substance can have on multiple areas of the body, why shouldn’t we screen for gluten sensitivity? As a means of prevention of further illnesses and a lower quality of life, the benefits in costs alone would outweigh the costs of screening.
How do we test everyone? Generally, everyone is tested with a saliva and blood evaluation of Anti-Gliadin Antibodies (IgG and IgA) as well as Anti-tissue Transglutaminase Antibodies (IgG and IgA). In small children we will consider an oral swab for genetic screening for HLA patterns. At the same time, we place all patients on a Modified Elimination Diet (MED) for 10 days that eliminates gluten and other common food allergies such as cow’s milk, corn and soy products, while invoking a good balance of healthy foods such as lean protein, vegetables and fruits. By assessing the response to the MED and the results of the diagnostic tests, we will receive a highly accurate assessment of gluten intolerance.
For us, the gold standard for diagnosing gluten sensitivity is not an intestinal biopsy or a blood test. It is a beneficial response to elimination of gluten in the diet. We have hundreds of patients that have benefited from this diagnostic approach of getting to the root cause.
Visit us at www.RootCauseMedicalClinic.com. If you have questions or need any help, I’m here for you! Call 408-733-0400.
I look forward to hearing from you.
To your good health,
Dr Vikki Petersen, DC, CCN, CFMP
IFM Certified Practitioner
Founder of Root Cause Medical Clinic
Co-author of “The Gluten Effect”
Author of the eBook: “Gluten Intolerance – What You Don’t Know May Be Killing You!”
Founder of Root Cause Medical Clinic
Co-author of “The Gluten Effect”
Author of the eBook: “Gluten Intolerance – What You Don’t Know May Be Killing You!”
Thursday, August 21, 2008
How Gluten Creates Problems in the Nervous System
A Reader named Anne writes: "I discovered my gluten sensitivity while trying to figure out something to help or reverse my small fiber peripheral neuropathy. My PN was progressing up my arms and legs. My feet were extremely painful - I had to sleep with them dangling off the side of the bed so nothing would touch them. I was also slightly off-balance, but the doctor said I was not ataxic."
"After going GF [gluten-free], I have seen regression in my PN. My arms and legs no longer tingle. I can sleep with my feet under the covers. I no longer limp and my balance is better. I doubt my feet will ever feel normal - too much damage. But they are so much better."
"Interesting, my son started complaining of foot pain when he was 20. He is now GF and says he no longer has any foot pain. Was that the start of PN? I wonder that as my foot pain began when I was 20. PN was not diagnosed until I was in my 50's. I was told it was planter fasciitis. Is there a connection between gluten and PF [peripheral neuropathy]?"
"I used Enterolab to confirm my gluten sensitivity. I have been gluten free for 5 years and the change in my health has been absolutely amazing. No more fatigue and depression. Improvement in peripheral neuropathy. Eyes and mouth are no longer dry. The list of improvements is very long."
"I stumbled across your blog this morning - nice find, will bookmark it. It is refreshing to find more doctors who are looking at the whole spectrum of gluten sensitivity and not just celiac disease. When will your book become available?"
I love Anne’s question and comment on her Peripheral Neuropathy (PN) because it brought Chapter 5 of my book to life. In Chapter 5 we discuss the various symptoms associated with gluten’s affect on a person’s nervous system. There are many such symptoms including clumsiness, imbalance, numbness, pain, memory and attention difficulty and mood disturbances. Two of these are exactly what Anne and her son experienced – pain of their extremities and imbalance.
In an effort to clarify why she noticed the benefits she did from removing gluten from her diet, please enjoy another snippet from our upcoming book:
Clumsiness and Imbalance
While this may not be the most common symptom of the nervous system related to gluten intolerance, it certainly is the most researched area. In medical circles, the term “ataxia” is used to describe poor coordination and balance. It can affect your walking, your ability to stand, or even your arms or legs in isolation. While many systems contribute to your balance (your inner ear, your vision, your sensations of your feet on the ground, etc.), your brain is the location that organizes all of this information and navigates your movements precisely. More specifically, the cerebellum, which is a part in the back of your brain, is the “balance control center.”
Some examiners claim that ataxia is one of the most common disorders produced by gluten in relationship to our nervous system. Poor coordination and clumsiness does occur with gluten intolerance and affects children as well as adults. But how does gluten cause our brains to function improperly and cause this imbalance? Evidence suggests that it is all due to the immune system’s reaction to gluten itself.
In your cerebellum (a part of the brain that plays an important role in the integration of sensation and control of movement), there are special cells called Purkinje cells. These cells are found in your cerebellum and are the main components of the “balancing center.” In patients with gluten sensitivity, it has been shown that these individuals have antibodies against these Purkinje cells. The antibodies made against gluten (anti-gliadin antibodies) cross-react against these Purkinje cells. What this means is that in a person who is genetically at-risk for gluten sensitivity, gluten induces an immune attack against the protein gliadin, and this antibody not only attacks gliadin, but also attacks tissues far away from the intestines. In this case, through the bloodstream, these antibodies travel to the cerebellum and attack the Purkinje cells. As these cells become inflamed from the immune attack, the ability to coordinate all the “balance information” is impaired. Symptoms of poor balance and coordination then result.
To further demonstrate this point, another study out of Britain examined 224 people with ataxia disorders. Some had an inherited disorder of ataxia, some had ataxia combined with other neurologic symptoms, and some simply had ataxia without known cause. Of those that were without known cause, 41 percent were found to have anti-gliadin antibodies supporting gluten sensitivity as a cause. Also, when looking at all the patients in these groups that were positive for these antibodies, 79 percent had “small” cerebellums on MRI testing. The gluten antibodies that had been generated from the immune system’s reaction were not only directed against gluten proteins, but also against the cerebellum and its Purkinje cells. Over time, the size of the cerebellum had decreased.
But the proof is always in the pudding. What happens if someone with poor balance is taken off gluten? In another study, ten patients with headaches and/or clumsiness were placed on a gluten-free diet. Over time, nine of the ten showed a beneficial response in all symptoms. The evidence is overwhelming. The presence of gluten antibodies, shrinkage of the cerebellum and the dramatic response to dietary change all support gluten as the cause. Yet despite these obvious factors indicating gluten (a dietary component) as the root cause, the majority of the time no digestive symptoms exist. In more than one study in patients with ataxia, other changes in the brain by MRI testing demonstrate inflammation and small areas of tissue damage. These changes occur silently without us even knowing it until they grow large enough to create symptoms. But by the time symptoms occur, the inflammation has been evolving over a long time for most people. For example, in individuals with small silent strokes to the brain where symptoms are absent, eventually enough tissue can be damaged to cause memory problems and dementia. By the time this is diagnosed, often more than 20 percent of brain is already damaged!
Think of your nervous system as an electrical circuit where information flows to and from the brain and spinal cord. Thousands of nerves traverse your body telling your muscles to move a certain way, and several sensors send information about touch, movement, pressure, temperature and pain back to your brain as well. When these nerves are unable to function well, “false” information can be sent back to the brain and cause many perceived symptoms. Of these, numbness, tingling and pain are the most common. If you have ever slept on your arm incorrectly, you know how uncomfortable the symptoms of numbness and tingling can be. Imagine having this all the time! If you slept in a poor position, as soon as you adjust and move, the compression on the nerve is released and the numbness fades away. In cases where the nerves are being damaged, however, changing your position does not help. This is called “neuropathy.”
Neuropathy can be due to many causes, and diabetes is the most common known cause. Unfortunately, the majority of neuropathies are without a known cause. In addition to ataxia, neuropathy is fairly well studied in relationship to gluten and is a common neurologic manifestation of gluten intolerance. The mechanism is related to the immune system. Antibodies directed against gliadin or gluten can result in cross-reactions against proteins or fibers of the nerves causing damage. Research supports that these antibodies have specific cross-reactivity with myelin (insulating layer around nerves composed of protein and fat) and neurofilaments (fibers that make up the nerve cell). Both of these are key components of nerves that relate to sensation and movement.
Depending on which portion and which set of nerves are affected will determine your symptoms. For instance, if nerves that sense temperature changes are attacked by gluten-related immune antibodies, then odd sensations of hot, cold or pain may develop. Or if nerves that sense pressure and touch are involved, unusual pressure sensations or deep pain can result. While it may seem that something which is hot, cold, or painful is affecting an area of your body, there is really nothing there. But your brain’s perception is purely based on what the nerves tell it. So, if they are signaling “bad” information because they are inflamed or injured, you still feel the pain even though nothing painful is there. In this way, it is like a short circuit in a faulty monitor. The monitor’s alarm is going off signaling a problem, everyone is hurrying to fix a problem, but no problem with the system is present. The problem is in the monitor, or in this case, the nerve itself.
How commonly does gluten cause these “neuropathy” problems? More often than you might think. In a study of 27 children with Celiac disease, 11 percent had some form of neurologic disorder. Neuropathy was the most common. Another examined nine patients with confirmed Celiac disease, and several different types of neuropathies were documented in this group affecting many different sorts of nerves. When you consider how few patients with neuropathy carry a documented cause to their complaints, gluten may well account for a high number.
"After going GF [gluten-free], I have seen regression in my PN. My arms and legs no longer tingle. I can sleep with my feet under the covers. I no longer limp and my balance is better. I doubt my feet will ever feel normal - too much damage. But they are so much better."
"Interesting, my son started complaining of foot pain when he was 20. He is now GF and says he no longer has any foot pain. Was that the start of PN? I wonder that as my foot pain began when I was 20. PN was not diagnosed until I was in my 50's. I was told it was planter fasciitis. Is there a connection between gluten and PF [peripheral neuropathy]?"
"I used Enterolab to confirm my gluten sensitivity. I have been gluten free for 5 years and the change in my health has been absolutely amazing. No more fatigue and depression. Improvement in peripheral neuropathy. Eyes and mouth are no longer dry. The list of improvements is very long."
"I stumbled across your blog this morning - nice find, will bookmark it. It is refreshing to find more doctors who are looking at the whole spectrum of gluten sensitivity and not just celiac disease. When will your book become available?"
I love Anne’s question and comment on her Peripheral Neuropathy (PN) because it brought Chapter 5 of my book to life. In Chapter 5 we discuss the various symptoms associated with gluten’s affect on a person’s nervous system. There are many such symptoms including clumsiness, imbalance, numbness, pain, memory and attention difficulty and mood disturbances. Two of these are exactly what Anne and her son experienced – pain of their extremities and imbalance.
In an effort to clarify why she noticed the benefits she did from removing gluten from her diet, please enjoy another snippet from our upcoming book:
Clumsiness and Imbalance
While this may not be the most common symptom of the nervous system related to gluten intolerance, it certainly is the most researched area. In medical circles, the term “ataxia” is used to describe poor coordination and balance. It can affect your walking, your ability to stand, or even your arms or legs in isolation. While many systems contribute to your balance (your inner ear, your vision, your sensations of your feet on the ground, etc.), your brain is the location that organizes all of this information and navigates your movements precisely. More specifically, the cerebellum, which is a part in the back of your brain, is the “balance control center.”
Some examiners claim that ataxia is one of the most common disorders produced by gluten in relationship to our nervous system. Poor coordination and clumsiness does occur with gluten intolerance and affects children as well as adults. But how does gluten cause our brains to function improperly and cause this imbalance? Evidence suggests that it is all due to the immune system’s reaction to gluten itself.
In your cerebellum (a part of the brain that plays an important role in the integration of sensation and control of movement), there are special cells called Purkinje cells. These cells are found in your cerebellum and are the main components of the “balancing center.” In patients with gluten sensitivity, it has been shown that these individuals have antibodies against these Purkinje cells. The antibodies made against gluten (anti-gliadin antibodies) cross-react against these Purkinje cells. What this means is that in a person who is genetically at-risk for gluten sensitivity, gluten induces an immune attack against the protein gliadin, and this antibody not only attacks gliadin, but also attacks tissues far away from the intestines. In this case, through the bloodstream, these antibodies travel to the cerebellum and attack the Purkinje cells. As these cells become inflamed from the immune attack, the ability to coordinate all the “balance information” is impaired. Symptoms of poor balance and coordination then result.
To further demonstrate this point, another study out of Britain examined 224 people with ataxia disorders. Some had an inherited disorder of ataxia, some had ataxia combined with other neurologic symptoms, and some simply had ataxia without known cause. Of those that were without known cause, 41 percent were found to have anti-gliadin antibodies supporting gluten sensitivity as a cause. Also, when looking at all the patients in these groups that were positive for these antibodies, 79 percent had “small” cerebellums on MRI testing. The gluten antibodies that had been generated from the immune system’s reaction were not only directed against gluten proteins, but also against the cerebellum and its Purkinje cells. Over time, the size of the cerebellum had decreased.
But the proof is always in the pudding. What happens if someone with poor balance is taken off gluten? In another study, ten patients with headaches and/or clumsiness were placed on a gluten-free diet. Over time, nine of the ten showed a beneficial response in all symptoms. The evidence is overwhelming. The presence of gluten antibodies, shrinkage of the cerebellum and the dramatic response to dietary change all support gluten as the cause. Yet despite these obvious factors indicating gluten (a dietary component) as the root cause, the majority of the time no digestive symptoms exist. In more than one study in patients with ataxia, other changes in the brain by MRI testing demonstrate inflammation and small areas of tissue damage. These changes occur silently without us even knowing it until they grow large enough to create symptoms. But by the time symptoms occur, the inflammation has been evolving over a long time for most people. For example, in individuals with small silent strokes to the brain where symptoms are absent, eventually enough tissue can be damaged to cause memory problems and dementia. By the time this is diagnosed, often more than 20 percent of brain is already damaged!
Think of your nervous system as an electrical circuit where information flows to and from the brain and spinal cord. Thousands of nerves traverse your body telling your muscles to move a certain way, and several sensors send information about touch, movement, pressure, temperature and pain back to your brain as well. When these nerves are unable to function well, “false” information can be sent back to the brain and cause many perceived symptoms. Of these, numbness, tingling and pain are the most common. If you have ever slept on your arm incorrectly, you know how uncomfortable the symptoms of numbness and tingling can be. Imagine having this all the time! If you slept in a poor position, as soon as you adjust and move, the compression on the nerve is released and the numbness fades away. In cases where the nerves are being damaged, however, changing your position does not help. This is called “neuropathy.”
Neuropathy can be due to many causes, and diabetes is the most common known cause. Unfortunately, the majority of neuropathies are without a known cause. In addition to ataxia, neuropathy is fairly well studied in relationship to gluten and is a common neurologic manifestation of gluten intolerance. The mechanism is related to the immune system. Antibodies directed against gliadin or gluten can result in cross-reactions against proteins or fibers of the nerves causing damage. Research supports that these antibodies have specific cross-reactivity with myelin (insulating layer around nerves composed of protein and fat) and neurofilaments (fibers that make up the nerve cell). Both of these are key components of nerves that relate to sensation and movement.
Depending on which portion and which set of nerves are affected will determine your symptoms. For instance, if nerves that sense temperature changes are attacked by gluten-related immune antibodies, then odd sensations of hot, cold or pain may develop. Or if nerves that sense pressure and touch are involved, unusual pressure sensations or deep pain can result. While it may seem that something which is hot, cold, or painful is affecting an area of your body, there is really nothing there. But your brain’s perception is purely based on what the nerves tell it. So, if they are signaling “bad” information because they are inflamed or injured, you still feel the pain even though nothing painful is there. In this way, it is like a short circuit in a faulty monitor. The monitor’s alarm is going off signaling a problem, everyone is hurrying to fix a problem, but no problem with the system is present. The problem is in the monitor, or in this case, the nerve itself.
How commonly does gluten cause these “neuropathy” problems? More often than you might think. In a study of 27 children with Celiac disease, 11 percent had some form of neurologic disorder. Neuropathy was the most common. Another examined nine patients with confirmed Celiac disease, and several different types of neuropathies were documented in this group affecting many different sorts of nerves. When you consider how few patients with neuropathy carry a documented cause to their complaints, gluten may well account for a high number.
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