19 minute read
Fire in my belly
B E L L Y FIRE IN MY Your gut and INFLAMMATION.
L T H O U G H
everyone experiences inflammation at times, problems with too much inflammation is an ongoing challenge for people living with an autoimmune disease. Inflammation is something that our body normally does when there is an injury, infection, or some other perceived “problem” in the body that needs to be fixed. It is usually associated with heat, redness, pain, and swelling, and is orchestrated by our immune system which plays a primary role in healing and regeneration.
Inflammation is neither good nor bad; if we experience an injury or come down with the flu, we want our immune system to respond with inflammation to heal. Usually the symptoms of an inflammatory reaction are not pleasant, but we would not be able to heal without it.
However, inflammation is not so good when it becomes chronic. [Nearly] all long-term health problems are linked to too much inflammation happening on a low-grade chronic level. Too much inflammation causes an overwhelm of painful symptoms that can show up in many areas of the body.
Coeliac disease (CD) is an inflammatory condition. That’s why it’s not surprising to see other inflammatory health problems such as bone loss, fertility issues, arthritis, muscle weakness, and skin conditions when CD is not well managed. When someone with CD is exposed to gluten, an inflammatory response develops in the gut, leading to an array of symptoms that our readers are familiar with.
Most people with CD find they are unaffected if they follow a strict gluten free diet. However, there are a proportion of people who experience ongoing inflammatory symptoms, even when gluten exposure is kept at bay. When there’s ongoing inflammation we need to look closer at
other issues happening in the gut. Gut inflammation can be linked to problems with gut bacteria (or microbiome), other problematic foods in the diet, problems with the gut lining barrier, and other environmental or lifestyle issues. If you are a highly sensitive person experiencing ongoing aches and pains, we’re going to explore some potential causes of inflammation.
Microbiome and inflammation Under normal healthy conditions, there are several populations of friendly “good” bacteria in our gut. These bacteria are known as the microbiome. One of their roles is to prevent invasions from the not-sofriendly “bad” bacteria and to regulate the way our immune systems interacts with pathogens as well as things coming through our diet. When there are imbalances to the gut microbiome, we can experience changes in our immune system which can lead to increased inflammation.
Imbalances in the microbiome have been linked to triggering inflammation in several ways. An overload of “bad” bacteria can alter structure and integrity on some areas of the intestinal wall. Having “bad” bacteria present in the wrong amounts can cause the gut lining to become inflamed. These changes can affect the way we process food and lead to a myriad of digestive symptoms such as pain, bloating, gas, and food intolerances.
This means that some people who have problems with their gut bacteria
may find they can eat a presumably healthy, gluten free, diet, but still react to food in a negative way. The process linking changes in the gut lining to chronic inflammatory diseases is known as intestinal hyper-permeability or “leaky gut”. As it progresses, intestinal hyper-permeability is linked to other chronic inflammatory issues.
Building a healthy gut barrier The good news is that gut bacteria and the cells that make up our gut lining are highly responsive to what we feed them. Our gut bacteria eat what we eat, meaning it’s down to the quality of our diets. Eating a diet that contains too much processed food is known to blunt some of the protective effects of good gut bacteria. Certain “bad” bacterial species will thrive of diets high in refined carbohydrate and sugars, making it important to limit these in our diets. Additionally, a lack of fibre and phytonutrients in highly processed foods can inhibit good bacteria from producing important nutrients which are needed to keep the gut lining cells healthy.
Failure to respond to a gluten-free diet after being diagnosed with CD can be due to several reasons: • Not following a strict GF diet and still eating small amounts of gluten. • Unknowingly ingesting unsuspected sources of gluten from crosscontamination or as an unexpected additive such as in medications or supplements. Having another co-existing condition such as irritable bowel syndrome, bacterial or fungal overgrowth, or colitis causing other digestive issues. Refractory disease or complications of CD.
WHY ISN'T GLUTEN-FREE WORKING?
To support a strong and diverse population of good bacteria you need to eat a wide variety of colourful plant foods – in their whole and minimally processed forms. That should include colourful vegetables, fruits, herbs, spices, teas, nut and seeds, and if tolerated, gluten free whole grains, beans, and legumes. Probiotic fermented foods may also help to diversify the microbiome. Some commonly known probiotic food sources include sauerkraut, kimchi, kefir, dry cured meat, yogurt, raw milk cheese, kombucha and miso.
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Environmental triggers Known to act like a second brain, our gut is highly sensitive to the wider environment and will react to all the usual environment stressors we experience. Research in animals and humans has suggested that stressful environments such as cold, heat, and chronic noise exposures can increase intestinal permeability, resulting in gut inflammation and changes to bacteria populations. Although people with CD are not exposed to stresses in the same manner done in the research, it does suggest that chronic psychological stresses may have a similar effect on the microbiome.
There are also many chemical environmental factors that could play a role in gut issues. Pesticides in particular are used profusely in our food supply and knowingly linked to negatively affect the gut and microbiome in numerous ways. Glyphosate, the active chemical in Round Up, has been shown to preferentially kill off “good” bacteria, selectively encouraging the growth of clostridia and pseudomonas species. Longterm changes in the gut microbiome related to chronic, low-grade pesticide exposure can increase the risk of intestinal hyper-permeability and chronic inflammation.
Lack of sleep is also an environmental stressor that reduces reactions are non specific and overlap. Those who experience ongoing gut issues since starting a gluten free lifestyle, should know they’re not alone. Research has shown several factors, beyond gluten, that can affect the gut barrier and microbiome, leading to inflammation. Getting to the real root of the issue is usually complicated and best undertaken with the guidance of a gut health expert, such as a specialist dietitian.
Exercise provides a range of health benefits which also play a role in supporting gut health. People who regularly exercise tend to have higher levels protective Lactobacillus and Bifidobacterium, also show higher levels of protective short chain fatty acids which play a role in reducing gut inflammation. However, since exercise is a stressor, too much or excessively intense exercise can be problematic. High intensity exercise can cause a lack of blood flow in the intestines, which if chronic, can increase stress hormones, inflammation, and lead to intestinal hyper-permeability. This means there is a “goldilocks” level of exercise for everyone, making the rest period equally as important. Conclusions Dealing with chronic symptoms related to CD can become very challenging when it seems like SYLVIA NORTH is a Registered Dietitian and Integrative Nutritionist, and a new member of Coeliac NZ’s Medical Advisory Panel. She specialises in creating individual approaches to addressing digestive problems and food intolerances, inflammatory conditions, hormonal problems, weight-loss resistance, and poor energy levels.
Although there are many unknowns when it comes to gut health and the microbiome, there are a few foundational strategies we all should be mindful of for general health. For the most part, choosing a diet based on unprocessed wholefoods is essential to provide prebiotics and polyphenols to “good” bacteria. The more nourished and diverse our microbiome is, the better it will be at keeping “bad” bacteria under control. CL our resilience. Inadequate sleep will suppress the immune system allowing and overgrowth of certain un-friendly bacteria. One of which is Klebsiella pneumoniae which is known to feed off refined off sugar and refined carbs.
____ • https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC6722800/ • https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC6996528/
Having 'bad' bacteria present in the wrong amounts can cause the gut lining to become inflamed. K N O W N T O A C T LIKE A S E C O N D
BRAIN, O U R G U T I S H I G H L Y S E N S I T I V E T O T H E W I D E R ... ENVIRONMENT...
WHAT IS REFRACTORY CD?
Refractory CD is a rare condition in which the symptoms of CD (and the loss of villi) do not improve despite many months of a strict gluten-free diet. Before making a diagnosis of refractory CD it is important to exclude complications of CD and other co-existing conditions. To diagnose refractory CD, the person needs to undergo a duodenal biopsy to examine specific changes in intestinal tissue and to rule out other potential underlying symptoms causes.
Now Gluten Free
Keeping SOCIALLY CONNECTED whilst living with a COMPLEX medical condition.
N U N E X P E C T E D
phone call at my desk one day heralded the opportunity to undertake a unique research study. At the other end of the line was a trustee of an estate advising that a bequest had been made to fund research into loneliness and social isolation ‘especially for those living with complex medical conditions’. A recent focus of my research has been on ‘social connectedness’, which refers to the quality and quantity of one’s social ties, and therefore I was excited to take up the challenge.
Social relationships play an important role across many aspects of people’s lives. As social beings, we thrive on interactions with others; I’m sure most of us would agree that activities are generally more enjoyable when shared. Socially well-connected people tend to be happier and more resilient, and to rate their subjective wellbeing higher than those without robust social ties. People with poor health, however, are at risk of lower social connectedness.
There were several components to the two year project but I would like to share a few of the preliminary findings from an online survey of people who self-reported that they had an ongoing medical condition that was substantially impacting their life and required treatments and services from multiple healthcare specialists, and who were aged 18-65.
Of the 305 survey respondents, 23 had coeliac disease (CD) – 15 reporting CD as their primary
medical condition (the one which they felt defined their medical status) and eight reporting it as a secondary condition. I will focus on the 15 people (average age 42 years, 14 female) who reported CD as their primary medical condition.
Although we cannot consider such a small sample to be representative of individuals with CD, the following responses may be of interest to readers.
The average time since diagnosis of CD was nine years. When asked whether they experienced any barriers to participating in social activities, 13 of the 15 CD individuals responded that they ‘Often’ found that their dietary needs were not met at social events, with the remaining two noting that ‘Sometimes’ these needs were not met
(all respondents therefore finding this a barrier at times). Food is, of course, often central to social gatherings
DR WENDY WRAPSON is a social psychologist and a Senior Research Fellow in the School of Public Health and
Interdisciplinary Studies at Auckland University of Technology. She worked as a researcher in the UK and Australia before taking up her role at AUT. and can present major challenges to people with CD to manage.
The potential for those with CD to withdraw from everyday events was also reflected in 10 out of 15 respondents reporting that, during the past four weeks, their health had interfered with their social activities ‘All of the time’. However, when survey respondents were asked ‘Are you content with the level of social interaction you have with others’, nine respondents answered ‘Yes’ and six respondents said ‘No’. This is somewhat encouraging as it suggests that, even with the challenges they experienced, the majority of our sample were coping with the social side of living with CD.
Nevertheless, while providing gluten free food at events has now become mainstream, it appears that there is still much to be done to ensure that those with CD feel they are catered for in any social setting. CL
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This research was conducted with the aid of a generous bequest from the estate of Dr Jeanette Crossley.
CERTTM
BOOCH ® ... THE WAY YOU LIKE IT
TREATING CHILDREN WITH RAISED
COELIAC ANTIBODIES
D I F F I C U L T
question that we often encounter in laboratory medicine is, “What does it mean when a child has raised coeliac antibodies, such as anti-tissue transglutaminase antibodies (anti-tTG), and a normal duodenal biopsy?”.
To date, there has been some evidence that approximately a third of these children will go on to develop an abnormal biopsy consistent with coeliac disease (CD), a third will simply “outgrow” the positivity on blood tests and not develop CD, with the remaining continuing to have antibody positivity and a normal biopsy.
A recent large study aimed to address the questions, “What
proportion of children with antibody positivity and a normal biopsy develop CD in long term follow up?” And, “Can we predict which children of these will develop CD?” This Italian study, recently published in the Journal Gastroenterology, followed 340 children aged 2-18 years who were shown to be repeatedly positive for anti-tTG antibodies, as well as antiendomysial antibody (EMA) and carried HLA DQ2 or DQ8 positive haplotypes, but did not have histological changes associated with CD on biopsy. Half of the patients were tested as they had a first degree relative with CD, while another 15% were tested due to a coexisting autoimmune condition, such as type 1 diabetes.
Sixty of the 340 children commenced a gluten-free diet
either because of symptoms suggestive of CD (mostly gastrointestinal) or due to parental choice. The remaining 280 children continued on a gluten-containing diet and were followed every 6 months for antibody testing and clinical features. A biopsy was performed every two years. Over the course of the study, patients were followed up for an average of 60 months (from a minimum of 18 months to a maximum of 12 years).
What did they find? On follow up, only a small number of children 42/280 (15%) developed a flat mucosa at the biannual histological evaluation, 89/280 (32%) of patients stopped producing antibodies, while the majority 166/280 (59%) continued to produce antibodies with ongoing normal biopsies. The authors did, however, note that the longer the patient was monitored, the more likely they were to develop CD, with 43% of patients who had been monitored for 12 years developing CD.
Was there a way to identify which children developed CD? The authors of this study identified a number of factors that helped identify children who were likely to develop CD over time. These included: 1. Children that developed flat mucosa over time showed an increased number of Gamma Delta lymphocytes in the first biopsy compared with children
who did not develop CD. Gamma Delta lymphocytes are an unusual population of inflammatory cells that are found mostly in the gut. An increased number of these cells suggests the initial stage of an inflammatory response. 2. The age at which the blood tests were positive. Only 7% children younger than 3 years of age developed flat mucosa compared with 51% of those enrolled between 3 and 10 years of age and 55% of those enrolled after 10 years of age. This means that especially in young children, transient antibody positivity may be a sign of a maturing gut (as is often seen in “allergic” IgE antibodies) and is not associated with the long term development of CD. 3. Double positivity (homozygosity) for the HLA DQB1*02 gene, meaning the greater the gene load the greater the chance of developing CD.
What does this mean for us in clinical practice? This is an interesting article that highlights children with no symptoms of CD but positive antibodies on blood tests should not be advised to go on a gluten free diet, especially if the child is under the age of three. These patients need to be monitored for changes in symptoms, antibody positive and possibly monitored with biopsies every second year. Hopefully this will be reassuring to parents who are understandably concerned about what to do when presented with this situation. CL
D R LO U I S E W I E N H O LT is
Manager of Business Development at the Royal College of Pathologists of Australasia
Quality Assurance Programs (RCPAQAP) and a lecturer at the Sydney Medical School,
University of Sydney. She has a Bachelor of Biomedical Science, a Master’s of Science in Medicine specialising in coeliac disease, a Doctorate of Business Administration focusing on quality in diagnostic pathology testing and is a Fellow of the Faculty of Science of the Royal College of Pathologist of Australasia in the discipline of Immunopathology. Louise is also a member of the Coeliac Australia Medical Advisory
Committee (MAC) and the Laboratory
Practice Committee of the Australian
Society of Clinical Immunology and Allergy (ASCIA). She has held a number of management roles in Immunology and
Infectious Serology and has co-authored over 20 peer reviewed publications.
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Article reprinted with permission by Coeliac Australia. The study cited in the article is Auricchio R, Mandile R, Del Vecchio MR, Scapaticci S, Galatola M, Maglio MA, Discepolo V, Miele E, Cielo D, Troncone R, Greco L. Progression of Celiac Disease in Children With Antibodies Against Tissue Transglutaminase and Normal Duodenal Architecture. Gastroenterology. 2019 Apr 9. The abstract is available at https://www.gastrojournal. org/article/S0016-5085(19)35671-9/abstract
SIX WEEKS IN EUROPE A gluten-free paradise
Verity Craft dishes up gluten-free TRAVEL TIPS and FOOD DESTINATIONS
RAVELLING when you’ve got coeliac disease can be tricky. Travelling for six weeks to multiple cities and countries can be even trickier – but I’m happy to tell you that it is completely possible! This past December and January, my husband Matt and I went on a belated honeymoon to New York and Europe. We wanted to experience a white Christmas, which we didn’t get – but we did manage to miss the fallout from COVID-19.
I was worried before we went about how we’d go food wise, particularly in places like Germany where their diet is very starch-heavy, and gluten abounds. Luckily, with a little research, I was able to find places for us to safely eat delicious meals in every place we visited. Here’s our coeliac-friendly odyssey through some of Europe’s most visited cities:
Gasthof Obermaier, Munich It’s a little hard going to Munich and not being able to eat the amazing Bavarian food or join in the frivolities at the beer halls. This traditional Bavarian restaurant will make up for it in spades, with a separate gluten-free menu (including gluten-free schnitzel!) and multiple gluten free beer options.
Palæo, Copenhagen This is a fantastic chain across Copenhagen which serves (obviously) paleo food options and is therefore 100% gluten free. We visited the one at the Torvehallerne Food Hall, which is also conveniently just a couple of minutes’ walk from Landbageriet (Naturbageriet), a bakery with a good range of gluten-free goodies.
Helmut Newcake, Paris I mean, have you even gone to Paris if you haven’t stuffed yourself full of pastries? Plenty of people have heard of Noglu, but my heart belongs to Helmut Newcake, a 100% gluten-free patisserie with a couple of locations in Paris. We skipped meals and instead just gorged ourselves on their delicious treats – and never regretted it! Just be ready to spend some money as you’ll be tempted by everything there.
Lily Burger, Berlin Lily Burger was so delicious we went back twice – they make insanely delicious and insanely huge burgers. They’re also famous for their vegan menu, so even if you’re not a meat eater there’s something for you.
Kivi Paber Käärid, Tallinn Loved being five minutes’ walk from this 100% gluten-free restaurant in Tallinn, Estonia – everything we tried over our three visits was delicious and it was so nice knowing that we could safely eat everything!
Leon, London It’s always awesome when you can go to a fast food place and actually eat there – and Leon is both fast and delicious. Good for a slightly cheaper but also healthier options, they have branches all over London. CL
TOP TIPS FOR TRAVELLING WITH CD
• Research, research, research – you can find coeliac-safe dining options in most cities; they’re just not always easy to find. Google restaurants look at gluten free travel blogs, and try using hashtags to find places on Instagram e.g. #glutenfreeberlin. • Create a list of recommended cafes, by country and link to Google Maps. Add notes about what kind of food it sells and what people had said about it (e.g. 100% gluten free vs. warnings to be careful to fully explain cross-contamination).
Then download those maps to use offline – this is super easy to do, just google how. Check which airlines do coeliacfriendly meals before you book – and keep snacks in your bag throughout the day (and especially for flights!) as you never know when you may not be able to access gluten free foods. • Book Airbnb or other accommodation that has a kitchen so you can at least sort breakfast and prepack another meal for on the go eating.
