Food Allergy, Gluten Sensitivity and Celiac Disease27.01.2014
by Campbel - Ralph
(OMNS Jan 21, 2014) What may have been called "food intolerance" or "food sensitivity" in the past may now qualify as "food allergy." On the other hand, certain conditions which mimic allergy symptoms should not come under that umbrella. We need an understanding of food allergy before successful management can be accomplished. There are no quick-fix remedies.
We tend to categorize by symptomatology, which accounts for the overlap of intolerance, sensitivity or true allergy: 1) nasal symptoms of stuffy nose and sneezing; 2) bowel symptoms of intestinal cramping or gas; 3) lung symptoms of wheezing and 4) skin that itches or produces a rash.
What is and Allergy, Really?
For decades, allergists have considered what we might call an allergic reaction to be a true allergy only if it is of the Th2 type (a type of immune cell) that produces measurable IgE antibodies. The other type, Th1, produces tissue antibodies that protect against infection. When a baby is born, it no longer has the protection of mother's antibodies, making it vulnerable to infectious diseases. The infant's immune system can take either route: the allergy pathway or the "fight infection" pathway. Residing in our cell membranes are hormone-like substances called prostaglandins. Treatment will be addressed later, but for now we need to understand a bit about "good" fatty acids vs. "bad" to see how the choice is made. Omega-6 fatty acids (as derived from grains), incorporated in a prostaglandin, leads to the allergy pathway, whereas the omega-3 fatty acids (plentiful in fish oils) in a prostaglandin influence the development of the Th1 antibodies.
Heredity seems to play a part in the predisposition to develop allergies as well as the mechanism I just described, which is more "nurture" than "nature." The predisposed cell, upon exposure to a food allergen (antigen), produces IgE antibodies which attach to mast cells. With further exposure, the food antigen (a protein in the food) reacts with the IgE type of antibody causing mast cells to breakdown and release histamine. It is the histamine, for the most part, that produces allergy symptoms. The food protein that remains intact by somehow escaping denaturing from heat or digestive processes, can become an antigen by sneaking into the blood stream via the "leaky gut syndrome" (the descriptive term for a porous gut) enabling distribution to cells in the nose, lungs or skin. For the gut, symptomatology may include colic-like cramping, mucus (even bloody mucus) in the stool, or irritable bowel syndrome that can produce either diarrhea or constipation. Nasal mucosal lining sensitization produces a stuffy, itchy nose or sneezing, while skin sensitization is manifest as eczema or topical dermatitis (both produce itching). Food allergens play a prominent part in wheezing; but so can irritants in the air, infection, and even exercise. The preservative, sodium sulfite, although certainly not a food itself, commonly contributes to wheezing and nasal symptoms.
I put allergy reactions into two categories: "rip-snortin,'" and those fitting Dr. William G. Crook's description of "hidden allergies". (Dr. Crook was a pediatric allergist and a pioneer in the science of food allergy.) Under the first category, I would include sneezing, wheezing, vomiting, intestinal cramping, hives and life-threatening, angio-neurotic edema. The hidden allergies are manifest by a plugged up, itchy nose, runny nose with post-nasal drip causing a rattly cough, or mild abdominal cramping with mucus in the stool. Exposure to more than one allergen at the same time may create symptoms where a single exposure will not - the important concept of "allergy load."
The severe reactions are clearly IgE antibody related, for which there are reliable tests. Even though there is documentation of milder allergies being on a different immune basis, this is given little attention, especially in infants with cow's milk allergy and the fact that they are often outgrown without the benefit of treatment.
Detection and Treatment
In a recent, very detailed study (1), a few workable, simple concepts come through among a maze of immunology jargon that only a few can comprehend. They contend that food allergy is increasing due to taking the Th2 pathway. A September 17, 2013 Reuter's Health article by Lorraine L. Janeczko reports the findings of Dr. Peter Gillet, a gastroenterologist at the Royal Hospital for Sick Children in Edinburgh. He feels there has been a 64% rise in food allergy over a twenty year period, there. Also America and several other countries are showing large rises. The rate of rise is much greater in a more recent five year period. However the increase is attributed to more awareness and more testing in which only IgE mediated allergy is accepted. This leaves me to believe there are many more undetected cases "out there".
The immunology study describes different types of tests, including the old standard of the prick or scratch skin test in which an antigen is scratched into the skin where the formation of a hive-like wheal is proof of allergy. They are taking new looks at old tests and treatment that were rejected in the past: oral specific, the "regular and gradual administration of escalating doses" and sublingual, in which the antigen rapidly enters the blood stream. In desensitizing a patient to a potent antigen, such as peanut, these methods are undertaken in the presence of a doctor who is prepared for the worst. Intricate immune pathways are presented in the article. The good news comes from the admission that they are "far from understanding the complex mechanisms leading to the successful results in allergen-specific immunology." We don't need to hold our breath while waiting for the full development of the new paradigm, but rather, utilize what we already know that works. A further admission is that the gold standard for testing for food allergy still is the oral challenge. This is strengthened by observing the short-comings of some of the tests in which the test occasionally may be negative, but the patient can still have a bad reaction with future contact. The flip side is that the test may be positive, but the patient has no clinical signs of allergy after exposure.
I know that for the pediatric population the elimination-and-challenge test is totally adequate and reliable for detecting food allergies and items like food colorings and other food additives. Remember that
- Symptoms arise within 2 hours after ingestion for most allergy problems, and that burning and itching sensations in the mouth or palate come immediately.
- Make a list of everything ingested that brings on those symptoms. Find commonality from your lists that leads to "suspects."
- Withdraw the suspects from the diet and note whether the allergy symptoms disappear.
- If adding back the suspect, one at a time, causes a return of symptoms, you have nailed a suspect. After a time of freedom from a reaction, periodically present a small, isolated challenge to see if the problem is still there. If not, reintroduce the food by gradually increasing doses.
Real Help with Vitamin C
Histamine, released in an allergic reaction, is the main chemical responsible for symptoms. Antihistamines are commonly prescribed. As with most medicines, there are side effects, most commonly drowsiness. Newer antihistamines claim to have less of this effect and to diminish symptoms better, but my personal experience does not bear this out. Response to these drugs is on an individual basis and varies. Fortunately, there is a natural remedy, without side-effects, that really works. That is vitamin C, due to vitamin C's ability to neutralize histamine. The minimal amount in a daily multivitamin or an orange won't do the trick, but for many adults 2,000 mg every 2 hours until symptoms subside, will. I have had this experience with my patients. According to weight, scale down the amount, but don't hesitate to give repeated doses if the initial dose doesn't finish the job.
Not Allergy, but Allergy Look-Alikes
Certain foods, such as red wines (with or without sulfites) and moldy cheeses create histamine release that is not on an allergy basis. Infection in the respiratory tree can create similar symptoms. No one is allergic to running, but in some, exercise triggers wheezing.
Lactose intolerance may cause intestinal distress of gas and mild cramping, similar to that derived from food sensitization, and act much like irritable bowel syndrome. Interestingly, there is a strong familial tendency for its development. Those of Asian decent are much more susceptible. Although straight cow's milk is poorly tolerated, the good news is that milk treated with lactose digesting probiotics, such as Lactobacillus acidophilus, is well tolerated. After weaning, many Asian infants go on to some form of fermented milk.
Gluten Sensitivity and Celiac Disease
Dr. Tom O'Bryan's article, "The Conundrum of Gluten Sensitivity," published in the National Health Federation's publication, Health Freedom News, showed that he had done his homework concerning the newer diagnostic tests that are providing a new look at gluten sensitivity as well as out-and-out celiac disease. He also described signs and symptoms of celiac disease outside the intestinal tract, which broadens its scope. I wish to provide a different slant on the subject that is derived from a pediatric point of view that extends from old time through current technological advances.
In my pediatric practice, I saw and successfully managed many cases of wheat allergy. At the same time, I had only one patient with classic celiac disease: a scrawny infant with the pathetic, heart-rending look of starvation and a flat area where his buttocks should be; a picture right out of the textbook. The best and only diagnostic tool for food allergy at that time was the food challenge. In the previously mentioned article in Immunotherapy by Enrique Gomez et al, the oral challenge was said to be the current gold standard as well. When positive, the infant/toddler was kept off of wheat for a time and periodically challenged, since wheat allergy, and the even more common cow's milk allergy, were known to clear spontaneously after a period of abstinence. Besides intestinal allergy symptoms, an infant with wheat allergy often exhibits nasal allergy signs which appear very shortly after ingestion of the allergen, making the relationship obvious.
I see a continuum of simple allergy to the auto-immune condition of celiac disease. I can't agree that it isn't celiac disease until the intestinal villi are completely destroyed. It is a process. True, once the immune system response is under way, the only way to stop it is to refrain from intake of any of the gluten-containing grains. Intestinal biopsy that searches for destroyed villi is the only reliable test. Discovering the multiple double-, triple- or polypeptides of gluten can lead to lots of tests. Since there are false negatives as well as false positives results to the tests, and all require blood-letting, even if I had had access to them, I would have not employed them.
Scientific curiosity drives us to look for the precise causes of disease. But if the motive for such specificity is to enable developing target patentable pharmaceuticals, it would be better not to look. Avoiding the antigen does the job well enough.
What I am seeing, especially in well-educated young people who have computer savvy, is self-diagnosis of gluten sensitivity derived from bombardment by the press, the Internet highway and TV news. It seems to be the in vogue diagnosis to have. An industry (much like the cholesterol industry) of gluten-free foods is springing up. It is difficult to motivate the "gluten-free" adherents to obtain differentiation between simple wheat allergy and celiac disease. What has happened?
Dr. O'Bryan's article and the Enrique Gomez article referred to above, agree that there has been a marked increase of incidence in the last few decades. A 2010 Medscape article referred to a Mayo study by Joseph Murray in which they analyzed stored blood samples of Air Force recruits in the 1950s for gluten antibodies. These antibodies were practically non-existent in the 50s samples but the article mentioned a large increase in incidence in the last three decades. Auto-immune diseases, in general, are on the increase. I believe that at the heart of these problems is the way we abuse our immune systems by direct attacks and nutritional deficiencies. Both diets and environmental toxins exposure have changed exponentially since the 50s.
Most current diets are very deficient in the vitamins that are essential as co-factors of enzymes that keep our metabolic wheels turning. Recommended Daily Allowances (RDAs) are barely able to prevent classic deficiency diseases like rickets or beriberi. I could fill pages with citations about the effect of environmental toxins on the immune system. A recent boon for those who treat allergy problems has been the gain in knowledge of omega-3 fatty acids (FAs). Whether the young immune system takes the Th1 pathway or the Th2 pathway that produces measurable IgE antibodies which mark "big time" allergies, is largely determined by the ratio of omega-6 FAs to omega-3 FAs. Rather than having closer to the ideal of 2:1, current diets create a ratio more like 20:1.The make-up of our prostaglandins (hormone-like substances in cell walls - ready to spring into action - is determined by the essential fatty acids in the mix: those provoking inflammation and clumping of platelets or those doing the opposite. The "leaky gut syndrome" concept is getting some new, deserved attention. Just what causes the gut permeability that can allow whole proteins to sneak from the gut into the blood stream and promote the antibody formation of simple allergy or auto-immunity in which the antibodies mistake normal body cells as foreign invaders?
We might keep trying to satisfy our scientific curiosity by seeking to pin-point the causes of food allergy, and auto-immune diseases that can be documented by specific tests. But should we wait for, or expect to be able to rely 100% on, new tests while other more straightforward, proven diagnostic tools are available? Let's not get bogged down with minutia. Rather, let us attempt to get straight, understandable information to the public that possibly could get them on a helpful, less cumbersome and less expensive track. Immune systems aren't functioning like they used to. A tangible effect is noted with antibody levels in response to various vaccines that are producing antibody levels well below the expected. I feel that the rapid rise in auto-immune diseases is getting away from us. Too often, drugs are not meeting our expectations. Let us concentrate on ways to improve immune health while continuing to identify the agents that weaken our immune systems. Immune health cannot be isolated from general health. Since it is nearly impossible in our culture to achieve a completely healthy diet, the intake of optimal amounts of vitamin supplements is essential.
(Dr. Ralph Campbell, board-certified in pediatrics, is also an octogenarian orchard farmer. He lives and works in Montana.)
1. Gomez E et al. Immunotherapy, 2013, 5(7): 755-768 pubmed Immunotherapy Gomez
For further reading:
Campbell R, Saul AW. The Vitamin Cure for Children's Health Problems. Laguna Beach, CA: Basic Health Publications, 2012.
Downing D. The Vitamin Cure for Allergies. Laguna Beach, CA: Basic Health Publications, 2010.
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