Free Weekly Digestive Health SmartBrief

A free weekly Free Digestive Health SmartBrief is available from The American College of Gastroenterology (ACG). Just enter your email along with your choice of gastroenterogist. If your doctor or someone in your area is not available you may choose Lewey, Scot, Colorado Springs as illustrated below.



You will receive a weekly newsletter that has tons of helpful information and updates from the ACG. Your email is secure and you may unsubscribe at anytime. I receive the physician's version and find it very informative and timely. The newsletter contributes to my goal of helping you achieve a "healthy gut, healthy life".

Sincerely,

Dr. Scot Michael Lewey
“Dr. Celiac, the food doc”
www.thefooddoc.com
info@thefooddoc.com
1699 Medical Center Point
Colorado Springs CO 80907


Copyright © 2008, The Food Doc, LLC, All Rights Reserved.
www.thefooddoc.com

Horizon Organic Products Are Gluten Free According to the Company But Inquiry Demonstrates Some Important Principles for Those on a Gluten Free Diet

Below is an email response to an inquiry my wife made to Horizon Organic about the presence of any gluten in their products. Since she has severe Celiac disease associated with the skin problem Dermatitis Herpetiformis she is extremely sensitive to even minute amounts of gluten that may be hidden in foods or be encountered as the result of cross contamination.

The email response illustrates a couple of important problems or challenges those of us trying to follow a gluten free diet encounter. First, gluten like grain proteins are found in barley and rye, not just wheat. Wheat is required to be disclosed on foods but barley, rye and gluten are not. Second, there is not yet a U.S. recognized and accepted definition of "gluten-free". The FDA is working on this issue but there is a political battle ongoing about what will be accepted as a "gluten-free" standard as some in the food industry are advocating an "acceptable level" of gluten set an certain parts per million allowed. Unfortunately, some Celiac disease experts appear to accept and advocate such an approach. Below is the company response to illustrate some of these principles.

"Thank you for your recent e-mail to Horizon Organic. We appreciate your interest in our products.

Currently, gluten is not considered one of the Big 8 allergenic foods (milk, peanuts, tree nuts, wheat, eggs, fish, shellfish and soy) and the Food & Drug Administration does not provide gluten-free labeling guidelines. However, our products do not contain wheat, barley, oats, rye, or malt, which are considered sources of gluten proteins. To the best of our knowledge, our products are free of gluten.

As with any food product, the best source for nutrient and ingredient information is the package's Nutrition Facts label. In addition, the Food Allergen Network, www.foodallergy.org, is an excellent resource for information related to this topic.

We hope this information is helpful.

Sincerely,
Priscilla Chotrani
Consumer Response Representative"

When trying to follow a gluten free diet remember the principle "caveat empor" always applies. That is "let the buyer beware". Always apply due diligence in checking any food item, restaurant, or meal for possible gluten or risk of gluten cross contamination. Then make your own decision based on your personal situation. You cannot assume any food that is processed is completely free of gluten unless it is tested specifically. Unfortunately, inexpensive commercially available tests for the presence of gluten are not readily available.


Copyright © 2008, The Food Doc, LLC, All Rights Reserved.
www.thefooddoc.com

Dr. Scot Michael Lewey
“Dr. Celiac, the food doc”
www.thefooddoc.com
info@thefooddoc.com
1699 Medical Center Point
Colorado Springs CO 80907

Your brain on gluten: Should you lay off the gluten before it's too late?

There is reasonable evidence of neurological problems in Celiac disease even those well treated on a gluten-free diet should undergo periodic neurological screening. Peripheral neuropathy is found in almost half of people with celiac disease. Previously, neurological complications in Celiac disease were reported to be as high as 36% or more than a third.

Some unexplained neurological problems are present but not recognized by the patient or their doctor in many patients and some have several problems. Unfortunately, since brain imaging is not routinely done or recommended in those who are newly diagnosed with Celiac disease we don’t really know how high these numbers may be really be. More staggering is the fact that we are still learning about people who fail to meet diagnostic criteria for Celiac disease but are being found to have gluten related neurological problems that respond to a gluten-free diet.

The symptoms of neuropathy are paresthesia (numbness) or dysthesia (burning, tingling, heaviness, “pins and needles” sensation”). Many of my patients also describe hypersensitivity of their skin such that they do not like air blowing on them or their children or spouses against their skin. Some admit to “bug crawling” sensation on their skin, something called vermiculation in medical terms but rarely asked about or given much thought by most doctors.

Odd muscle movements under the skin that some call a “bag of worms” medically known as fasiculations are also very common but dismissed by many doctors. My wife, a physician with Celiac disease, actually had these occur while undergoing an EMG (electromyleograph, recording of muscle activity by placing needle electrode into the muscle) exam by an older neurologist. Despite observing these occurring visually and the monitor showing “static like noise” the neurologist dismissed them as “normal”.

Many patients with Celiac disease also have what the radiologists and neurologists call “UBO’s” on MRI exams of the brain. These unidentified bright objects (think UFO) are white spots that show up on images of the brain. When found in certain locations of the brain they are highly suggestive of multiple sclerosis (multiple scarring spots in the brain). However, though many people with Celiac disease have MS like symptoms and these symptoms often respond to a gluten free diet when started early enough, the UBO’s seen on MRI of the brain are typically not in the classic areas of MS. Instead it is common to find them in areas of the brain associated with migraines or balance difficulty (ataxia).

Personally and professionally I have observed all of the neurological complications of Celiac disease and most of them I have also noted in patients in whom I have not been able to confirm Celiac disease but who have what I believe are objective signs and/or genetic risk for gluten sensitivity. I have patients with MS-like symptoms, chronic unexplained neuropathy, headaches, attention difficulties, autistic behaviors and developmental delays who have responded to gluten-free diet but if they had listened to doctors who maintained such a “restrictive, expensive, hard to follow” diet should only be “imposed” on those with a established diagnosis of Celiac disease.

If you have neurological problems get testing for Celiac disease before starting a gluten-free diet. If you test negative for Celiac disease, make sure they test you for the complete HLA DQ genetics that includes the high-risk white blood cell patterns DQ2 and DQ8 for Celiac disease AND get your Celiac disease blood tests include IgG and IgA gliadin antibodies. If your blood tests, including gliadin IgA and IgG antibodies, are negative or normal then consider stool testing for gliadin antibodies in the stool ($99, www.enterolab.com).

The evidence continues to accumulate, though often ignored or missed, that gluten is toxic to some people’s brains, even if they do not have Celiac disease. If you do have Celiac disease it is likely you already have neurological problems and may be at risk despite being on a gluten-free diet.

Borrowing from the old advertisement against drug abuse “this is your brain on drugs” maybe we should be getting the word out “this is your brain on gluten”. Despite your test results, consider a trial of gluten-free diet after you have your testing done if you have unexplained or unresponsive neurological problems. You owe to your brain. Like my seven-year-old son said to one of our friends, “maybe you should lay off the gluten”.


Copyright © 2008, The Food Doc, LLC, All Rights Reserved.
www.thefooddoc.com

References:Del Giudice, E. "Subclinical Neurological Involvement in Treated Celiac Disease: The Dark Side of Gluten-related Encephalopathies" Journal of Pediatric Gastroenterology and Nutrition 2007; 45:290-292.

Dr. Scot Michael Lewey
“Dr. Celiac, the food doc”
www.thefooddoc.com
info@thefooddoc.com
1699 Medical Center Point
Colorado Springs CO 80907

Mastocytic Enterocolitis Associated Food Intolerance Missed Due to Lack of Special Stains of Intestinal Biopsies and Celiac Gene Testing?

Increased mast cells have been reported in association with eosinophils in the gut in patients with celiac disease and inflammatory bowel diseases like ulcerative colitis and Crohn’s disease condition. Mastocytic enterocolitis (entero=small bowel, colitis- colon + -itis= inflammation) is a newly recognized disorder defined specifically by the microscopic presence of increased mast cells (>20 mast cells/high power field) in the gut, typically associated with abdominal pain and diarrhea diagnosed as IBS-D.

Mast cells are a type of white blood cell important in immune defense. These “covert” cells are hard to see in the lining of the gut without special stains. Therefore, they have been not recognized as being increased in the gut until recently when this association was found with IBS.

Mast cells have granules that contain chemical mediators such as histamine. These mediators are released resulting in pain due to irritation of nerves. Diarrhea is most commonly noted but impairment of nerves can result in opposite effects on gut movement.

Since routinely looking for mast cells in small bowel and colon biopsies about a year ago I have diagnosed more 35 patients with mastocytic enterocolitis. Interestingly, there appears to be a very strong correlation of this condition with HLA DQ2 and DQ8, white blood cell protein pattern types genetically determined and inherited that are highly associated with celiac disease and gluten intolerance. In my experience, those with this condition have a high risk of gluten and other food protein sensitivity or intolerance. A combination of food elimination based on food allergy and sensitivity testing (Signet Diagnostic Corporation, MRT or Alcat food intolerance testing) with use of histamine blockers, oral steroids including budesonide (Entocort EC), or the mast cell stabilizer sodium Cromalyn (Gastrocrom).

Unfortunately, most patients undergoing evaluation for abdominal pain, diarrhea, gas-bloat or nausea either do not have biopsies of normal appearing intestinal tissue or that tissue is not stained with special stains to look for mast cells. As a result I believe many with this treatable condition are being missed despite undergoing invasive diagnostic endoscopy (scope) exams. Further studies are needed to look into the association of HLA DQ genetic patterns and the helpfulness of food intolerance tests combined with specific elimination diet based on these results.

I am attempting to get a research protocol designed, approved and funded to look into this link. There continues to accumulate mounting evidence of the role of food proteins, dietary yeast and gut bacteria and yeast in the development of a wide variety of symptoms and diseases, especially inflammatory bowel disorders including celiac disease, Crohn’s disease, ulcerative colitis, microscopic colitis, eosinophilic gastrointestinal disorders, and now irritable bowel syndrome. Our goal is a “healthy gut, healthy life” and to provide useful information to those who follow the Food Doc blog to achieve this goal.


Jakate S, Demeo M, John R, Tobin M, Keshavarzian A. “Mastocytic enterocolitis: increased mucosal mast cells in chronic intractable diarrhea.” Arch Pathol Lab Med. 2006 Mar;130(3):362-7.

Barbara G, Wang B, Stanghellini V, de Giorgio R, Cremon C, Di Nardo G, Trevisani M, Campi B, Geppetti P, Tonini M, Bunnett NW, Grundy D, Corinaldesi R. “Mast cell-dependent excitation of visceral-nociceptive sensory neurons in irritable bowel syndrome.” Gastroenterology. 2007 Jan;132(1):26-37.

Park JH, Rhee PL, Kim HS, Lee JH, Kim YH, Kim JJ, Rhee JC. “Mucosal mast cell counts correlate with visceral hypersensitivity in patients with diarrhea predominant irritable bowel syndrome.”
J Gastroenterol Hepatol. 2006 Jan;21(1 Pt 1):71-8.

Barbara G, Stanghellini V, De Giorgio R, Cremon C, Cottrell GS, Santini D, Pasquinelli G, Morselli-Labate AM, Grady EF, Bunnett NW, Collins SM, Corinaldesi R. “Activated mast cells in proximity to colonic nerves correlate with abdominal pain in irritable bowel syndrome.” Gastroenterology. 2004 Mar; 126(3):693-702.

Yeast Sugar Also Found in Cow’s Milk Linked to Crohn’s Disease

A new report suggests that a sugar found in Cow’s milk, contributes to the development of Crohn’s disease. This sugar mannan is also produced by the dietary yeast, Saccharomyces cerevisiae or common Baker’s or Brewer’s yeast used to bake bread and brew beer. Mannan has been shown to make white blood cells lazy and allow overgrowth of the bacteria E. coli. Both Saccharomyces cerevisiae yeast and E. coli bacteria are linked somehow to Crohn's disease based on the presence of antibodies in the blood to them found in most people with this chronic incurable bowel disorder.

Interestingly, antibodies to the yeast abbreviated ASCA are found in many people with Celiac disease and in some people with IBS. I have several patients with ASCA antibodies who have Celiac disease, mastocytic enterocolitis, microscopic colitis, IBS and other undefined conditions that I believe are a form of a leaky gut disorder. Many of these people have evidence of multiple food intolerance and non-celiac gluten sensitivity. Most improve with a gluten free diet combined with probiotics and when necessary steroids, or other Crohn's and colitis type medications.

There has been a theory for years that Crohn’s disease results from an infection. A cousin to the TB bacteria known as mycobacterium paratuberculosis is high on the suspect list because it causes a disease in sheep called Johannes’s disease that is nearly identical to Crohn’s disease in humans. Some researchers have reported evidence of this bacterial infection in patients with Crohn's disease though I could not find evidence of DNA of this bacteria or RNA of the measles virus in biopsy tissue using PCR techniques during research I did while in my GI fellowship training. Treatment directed against M. paratuberculosis has helped some Crohn’s patients further fueling the debate about its role.

More recently the focus on the role of a dietary yeast Saccharomyces cerevisiae is heating up since up to two thirds of Crohn’s disease sufferers have antibodies to this yeast in their blood, abbreviated ASCA. In addition the presence of antibodies to the outer membrane protein (OmpC) and flagella (anti-CBir1) of the bacteria E. coli has it in the fray as well along with the yeast Candida albicans that may somehow assist in the toxicity of Saccharomyces cerevisiae.

Mycobacterium paratuberculosis apparently sheds mannan, this yeast sugar also found in Cow’s milk. M. paratuberculosis bacteria and the other suspect yeast in the digestive tract, Candida albicans, also apparently trigger the development of ASCA antibodies. These researchers theorize that the presence of ASCA antibodies found in Crohn’s disease patients indicate prior infection with M. paratuberculosis bacteria. It is interesting to wonder if such an infection is a trigger for leaky gut that can precipitate various digestive symptoms as well as diseases, depending on the location of the gut injury and a person's genetic make up and environmental influences including stress, diet and gut bacteria levels.

Mannan shed by this bacterium causes white blood cells known as phagocytes (phago-eat, cytes-cells) that normally eat foreign invaders become lazy. Granulomas, collections of dead cells and debris, and abnormal connections between tissues known as fistula typical of Crohn’s disease result.

Currently, there is no cure for Crohn’s disease and the only treatments involve suppressing the body’s immune system with powerful drugs such as the steroid prednisone, biologics Remicade and Humira, and anti-cancer/anti-inflammation drugs Immuran/azothioprine, 6-mercaptopurine or methotrexate. More recently, probiotics have been showing great promise. Probiotic bacteria in preparations such as VSL#3 and the probiotic yeast Saccharomyces boulardii, a cousin of Saccharomyces cerevisiae are effective in preventing and treating Crohn’s disease to some degree in laboratory rats and humans.

Of interest is that the carbohydrate specific diet espoused by Elaine Gottschall in her book “Breaking the Vicious Cycle” limits dairy and yeast intake. This diet advocated by many for treatment of Crohn’s disease based on numerous patient testimonials of its effectiveness. Since no controlled trials have been done proving it is effective, it is not advocated by most traditional medical practitioners. The Crohn’s and Colitis Foundation of America reviews the diet on its website pointing out the pros and cons. Many of us open to the role of diet in bowel inflammation suggest it to our patients as an option.

This new data on yeast sugar mannan, found in Cow’s milk, and gut bacteria is further support of the role of diet, bacteria and yeast in bowel damage and injury. The leaky gut and hygiene theory continue to become entwined with food, bacteria and yeast proteins and sugars in human disease. What you eat and what is living in your gut are important to your health. That is why the Food Doc motto is a “healthy gut, healthy life”.

Reference: Gastroenterology 2007;133:1487-1498

Copyright © 2008, The Food Doc, LLC, All Rights Reserved.
www.thefooddoc.com