Monday, May 23, 2011

Gluten Contributes to Irritable Bowel Syndrome Even in Non-Celiacs

Someone, Dr.Elena Verdu wondered if gluten might contribute to IBS and she did a study. She's discovering what others have discovered, that there is an entity, "non-celiac gluten sensitivity" where people who don't fit the diagnosis of celiac, get better on a gluten-free diet. I know it's real. It has a higher rate of morbidity and mortality, compared to the general population, according to Ludvigsson. He says:"Patients with mild inflammation and gluten sensitivity have a higher risk of death, even if their symptoms are not severe enough to warrant a diagnosis of full-blown celiac disease."

As for the notion that non-celiac gluten sensitivity is milder than celiac disease, Anderson et al, in their study titled “Malignancy and mortality in a population-based cohort of patients with coeliac disease or ‘gluten sensitivity’ World J Gastroenterol 2007 January 7; 13(1): 146-151, report a higher rate of malignancy and early mortality among those with non-celiac gluten sensitivity than among those with celiac disease.  This finding may be the result of the common recommendation that patients ignore test results that show non-celiac gluten sensitivity, as many physicians believe that such results are “non-specific” and do not warrant a gluten free diet

Let's hope there are more studies to help us sort things out. This study is reported by Diana Gitig PhD at 05/18/2011

“Irritable bowel Syndrome (IBS) is based on a clinical description only; there are no pathophysiological pathways definitively associated with it. It is characterized as gastrointestinal symptoms with no discernable cause. A diagnosis of IBS depends on recurrent abdominal pain or discomfort for at least three days per month in the last three months, with the onset of the discomfort either associated with a change in frequency or appearance of stool or alleviated by defecation. A number of different mechanisms have been suggested as potential causes of IBS. These range from psychological origins, to increased visceral hyperalgesia (sensitivity to pain), to the low grade gut inflammation and altered gastrointestinal permeability and motility observed in IBS patients. Complicating matters is that most patients exhibit only a subset of symptoms. Since gluten has been demonstrated to negatively affect even people without celiac disease by an unknown mechanism (see Study Shows Gluten Intolerance Without Celiac Disease), and the underlying causes of IBS remain unclear, Dr. Elena Verdu wondered if gluten might contribute to IBS.

Like those with IBS, patients with gluten sensitivity lack the antibodies against tissue transglutaminase that are the hallmark of celiac disease but nonetheless suffer immune mediated inflammation in their gut. Interestingly, when IBS patients without celiac eliminated gluten from their diet, 68% of them reported more severe pain, bloating, and tiredness upon gluten rechallenge. But how?  By what mechanism? No changes were detected in intestinal permeability or fecal lactoferrin, a marker of intestinal inflammation. However, it is possible that these phenomena persisted, just at below the level of detection.

Based on these data, and other evidence that is rapidly accruing suggesting that gluten can negatively affect those without celiac disease, Dr. Verdu suggests that IBS patients might be screened for anti-gliadin antibodies even if they lack antibodies against tissue transglutaminase. These nonspecific antibodies can indicate an immunological response to gluten, and thus their presence could used to determine if their symptoms might be alleviated by adherence to a gluten free diet. She makes sure to point out, though, that this is probably not the case for all IBS patients.

Read the abstract here Am J Gastroenterol 2011; 106:516–518

Intestinal Permeability
The trigger for so many diseases caused by gluten sensitivity appear to come from "intestinal permeability" which is found at the microscopic level. With or without villous damage. Here is a schematic representation of "intestinal permeability" and look at the bottom and see the influence on the immune system especially Th2CD4 and it's effects on Mast cells and ultimately the brain.

Esophageal Cancer risk doubled in Bisphosphonate (Fosamax,Actinel) use if over 5 years.

This result is reported from the team of Green J, et al from Cancer Epidemiology Unit, University of Oxford, Oxford OX3 7LF published in BMJ.  2010 September 1; 41:c4444. This particular study in the British Medical Journal involved 80,000 patients tracked for more than seven years on average.  This documents the long-term harm of these very toxic, inflammation producing drugs that do not build or rejuvenate healthy bone but poison osteoclastsSo why am I discussing this …….on a celiac blog. What if most osteoporosis cases are undiagnosed celiac/gluten sensitive persons? What if treatment of osteoporosis is the testing for celiac and if found to be so, a gluten-free diet and supplements? And if not celiac, prescribe a trial of a gluten-free diet and supplements and monitor.

But osteoporosis rates are extremely high especially in undiagnosed celiac. And remember there are 10- 13 undiagnosed persons with celiac for every one diagnosed. So gluten-eating persons with celiac disease, already prone to GI cancers and osteoporosis, are often treated with a bisphosphonate drug such as Fosamax and Actinel. And, because of their poor effectiveness, a finding reported in a January 2008 issue of the Annals of Internal Medicine (full article here), gluten sensitive people end up using them for long periods of time.
Cancer rates, especially GI cancers, are reportedly much more common in persons with celiac (and I assume those with gluten sensitivity too) who are eating gluten and within the first 5 years of stopping eating gluten. (The exact rate is difficult to nail down due to poor reporting of the diet in the groups studied, but let’s say 2-4 times higher than the normal population, according to Dr. Farrell, NEJM, 2002). Studies have shown cancer rates decrease to normal rate of 1, after five years of a gluten-free diet.

And what if bisphosphonates are not the first line of therapy for osteoporosis? So says a University of Illinois study which finds that an effective first course of action is increasing dietary calcium and vitamin D or taking calcium and vitamin D supplements.
For many people, prescription bone-building medicines should be a last resort,” said Karen Chapman-Novakofski, a U of I professor of nutrition and co-author of a literature review published in a recent issue of Nutrients, May 2011.

If a person knows they have celiac or gluten sensitivity they must only bisphosphonates as a last resort after trial of supplements as described below and a gluten-free diet. There are many other hazards of bisphosphonates including the direct side effects of osteonecrosis of the jaw, atrial fibrillation ( which requires long term use of blood thinning drugs to prevent strokes), pain syndromes and inflammation of the esophagus. See Byron Richard’s excellent summary of the hazards of bisphosphonates found here, atThe Delusions of Bone Drugs". 

Also it is well known that a gluten sensitive/celiac person who stops gluten ingestion will gain about 4% bone per year, just by that one maneuver. Adding good food, supplements of Vitamin D, calcium, magnesium, boron and strontium oratate also helps to bring the bone growth up to 20% per year (my personal observation in my patients).

Dr. Gaby's book "How to prevent and treat Osteoporosis" is wonderful resource and can be purchased at any book store.

Oesophageal cancer is not common in Western countries, but it has a high morbidity and is often fatal. On the basis of incidences for Europe and North America published by the World Health Organization in 2007,6 a doubling of risk of oesophageal cancer associated with about five years’ use of oral bisphosphonates would mean an estimated overall increase in incidence of oesophageal cancer in people aged 60-79 years from 1 case per 1000 population over five years in both sexes combined (in women 0.5 and in men 1.5 per 1000) in non-users to 2 cases per 1000 over five years (in women 1 case and in men 3 cases per 1000) in users.
If confirmed, an association between use of oral bisphosphonates and risk of oesophageal cancer would add to our knowledge of the risks and benefits of use of oral bisphosphonates. Treatment and prevention of osteoporotic fracture is a subject of increasing public health importance with large scale clinical and economic implications. Further research is warranted to confirm or refute our findings and in particular to examine the associations between use of different types and formulations of bisphosphonates and risk of the different histological types of oesophageal cancer.

Even one prescription for any type of bisphosphonate drug increases the risk of esophageal cancer by 20%.  However, when a person fills 10 or more of these prescriptions for longer than a three year period, which is standard medical protocol, then the risk doubles (200%). 

With osteoporosis, think celiac/gluten sensitivity!