Sub-Clinical Gluten Enteropathy
The "Classical Presentation" is the Exception, not the Rule
Obesity is now endemic. More than a national disgrace, the fattening of America may well be one of our greatest threats to our national security. In North America , the general public spends huge sums of money in futile effort to lose weight, when simultaneously, we are wasting huge sums of money ignoring what may be the treatable cause of weight gain in a large percentage of the population. Gluten Enteropathy is a common cause of weight issues in populations that consume grain as a diet staple.
Celiac Disease (CD) is a digestive disease that damages the small intestine and interferes with nutritional absorption, and it can result in unexplained weight gain. Sufferers of Celiac Disease cannot tolerate gluten, a binding protein found in wheat, rye, and barley. Most commonly, gluten is found in food products, but Gluten may also be found in everyday products such as medicines, vitamins, and cosmetic products.
Sensitivity to Gluten is very common. Affecting as many as 30% of the general population, sensitivity to gluten is a "spectrum disorder." That is, it varies from Subclinical-mild in severity to overwhelming-devastating. In its severest form, it is known as Celiac Sprue, Celiac Disease (CD), non-tropical Sprue, and less commonly as Gee-Herter Disease, Gee-Thaysen Disease or Heubner-Herter Disease.
Celiac disease is both a disease of malabsorption, and an immunological condition. There may be a familial or genetic predisposition to CD, and it may be triggered after trauma, surgery, pregnancy, childbirth, infection, or emotional stress. Autoimmune in nature, Celiac Disease sufferers will experience periods of time where symptoms are minimal, stable and flair. Triggers are usually dietary, as the protein family known generally as "Gluten" will trigger complaints in most patients. Equally confusing is that hormonal shifts, co-morbid disease states, infection and stress can trigger symptoms, as well.
Clinical Presentation: Misdiagnosed as "irritable bowel disease," Celiac Disease is a life-long complaint. Rare is the patient that presents to the office complaining of the "classical presentation" of dramatic weight loss, diarrhea and cramping precipitated by pizza, spaghetti and bread. More typically, patients present with peculiar, episodic cramping, bloating and weight gain. Self-diagnosed with "leaky gut," they often go through an embarrassing series of self-treatment protocols, GI detoxifications and fad diets. A minority of patients present with skin rash known as Dermatitis Herpetiformis, as the principal symptom.
Other Signs and Symptoms Include:
- unexplained iron-deficiency anemia
- fatigue, depression, anhedonia, anxiety
- arthritic bone or joint pain
- bone loss, osteopenia, or osteoporosis
- tingling numbness in the extremities
- seizures, depression, bipolar disorder
- canker sores in the mouth
- dermatitis herpetiformis
The most common complaints are dyspepsia, bloating and abdominal uneasiness.
Associated disorders include:
- Autoimmune thyroid disease, e.g. Hashimoto's Thyroiditis, Grave's Disease
- Autoimmune liver disease
- Rheumatoid arthritis
- Autoimmune adrenal dysfunction; Addison's Disease
- Sjgren's syndrome
- Bipolar Disorder
Diagnosis: To most medical practitioners, blood work is the preferred approach to diagnosis, elimination diet is often the most practical way to infer diagnosis. Elimination of gluten from the diet for a 2 week period is often all that is necessary to infer diagnosis. The "gold standard" in confirming diagnosis is the endoscopic biopsy. When positive, diagnosis is firmly established. Unfortunately, biopsy for Celiac Disease is fraught with false negatives. Easiest of all is testing, serum anti-body determinations for IgG, IgA, IgE and tTG IgA and tTG IgE are useful, but the derived information is sometimes confusing. Best drawn early in the morning, these antibody titers may demonstrate patterns that suggest gluten sensitivity or frank Celiac Disease.
Nutraceutical Treatment of Celiac Disease
The mainstay of treatment is as simple and as complicated as avoiding Gluten in the diet. This means avoidance of most processed foods, and nearly all grains. Gluten is widely used as a binder in medicines, supplements and in many cosmetic products. It takes a good bit of research to identify sources of Gluten in the ingestible environment, and it takes but a single slip to cause a patient to go into a gastrointestinal crisis.
- CLA- Conjugated Linoleic Acid. When taken 1,000 mg two or three times daily, CLA will act as a topical anti-inflammatory for the GI tract. Taking a week or two, symptomatic relief can be dramatic.
- Castor Oil- This old standby is useful to settle an inflamed GI tract. Taken Tsp to Tbs in apple sauce, once daily, the irritable bowel symptoms often abate within a few days. It should be taken for several weeks, consistently, then periodically as symptoms dictate.
- DPP IV (gluten digestive enzyme)- One or two capsules taken immediately before meals will provide some protection from modest amounts of Gluten. Taking these digestive enzymes mitigates but does not eliminate the damage from dietary gluten, but social circumstances sometimes dictate the need for this intervention.
Celiac Disease results in an unpredictable but inevitable malabsorption of essential vitamins, minerals, amino acids, oils and essential fatty acids. Many nutritional deficiency syndromes are easily detectable through available nutritional test panels. Most practitioners are unfamiliar with these panels making specific intervention impossible.
General supplementation should include:
- Mineral chelate (organic mineral salts)
- Essential Fatty Acids & Oils
- Amino Acid/protein supplementation
- Vitamin B Complex, Vitamin C, Vitamin E
- Vitamin D-3 (dosage dictated by age and condition)
As we age, we become less and less efficient in absorbing nutrients through the gastrointestinal tract. With Celiac Disease, this efficiency deteriorates even more dramatically. In short, it takes a great deal more than the "recommended daily allowance (RDA)," to ensure adequate levels of these important and inexpensive nutrients.
NOTE WELL: The commonly available OTC multivitamin/mineral complexes are entirely inadequate.
Individuals with Celiac Disease tend to have elevations in CRP (C-reactive protein), suggesting increased risk of cardiovascular disease. Omega-3 fatty acid (fish oil) administration is an interesting, new intervention for the treatment and prevention of coronary artery disease (CAD). Certain omega-3 fatty acids have biochemical properties that promote atherosclerotic plaque stability and thereby decrease the incidence of cardiac ischemia and ischemic cardiac arrhythmias.
An ever-increasing body of evidence supports the role for omega-3 fatty acids, i.e. fish oil, in through a role as anti-arrhythmic agents, through anti-thrombotic effect, and through atherosclerotic plaque stabilization, probably as a result of topical anti-inflammatory action. Dosage requirement is between 2 and 3 grams per day, in divided doses. Generally, the preferred cardiac ratio of 3:2 EPA/DHA, but in inflammatory conditions such as Celiac Disease, the EPA/DHA ratio does a bit better at 6:1. Patient should begin with 1 mg per day, increase over a week or two to the desired daily dosage.
David S. Klein, MD has practiced pain medicine for the past 27 years and is the author of over 50 published articles and textbook chapters and has lectured extensively. He is a member of the American Board of Anesthesiology, American Board of Pain Medicine, American Academy of Pain Management, American Board of Minimally Invasive Medicine & Surgery, and has Sub-Specialty Certification in Pain by the American Board of Anesthesiologists.
Dr. Klein is presently the Medical Director of the Pain Center of Orlando, located at 225 W. SR 434, Suite # 205, Longwood, Florida 32750
Telephone 407-679-3337, FAX: 407-678-7246.