March 13 -20 is Coeliac Awareness Week
Coeliac Disease is an autoimmune disorder causing small bowel damage. An autoimmune response is triggered by the consumption of gluten, a protein found in wheat, barley and rye and results in the damage of intestinal villi – tiny, finger-like projections which line the bowel.
Imagine a grass lawn, with all its individual blades of grass. Villi are like these individual blades of grass. They increase the surface area of the gut – if we were to iron them out, the total surface area would be the equivalent of 2 tennis courts. This huge surface area improves our ability to absorb nutrients.
Now imagine driving a lawn mower over that lawn and razing down all those blades of grass. That is pretty much what happens in Coeliac disease – we call it villous atrophy. The result is a reduced surface area of the bowel available for nutrient absorption, which can lead to various gastrointestinal and malabsorptive symptoms. The underlying inflammatory process leads to a variety of other symptoms (thyroid issues, infertility, bone loss… ) and increased susceptibility to another autoimmune disease.
How is Coeliac Disease diagnosed?
Coeliac disease affects on average approximately 1 in 70 Australians. However, around 80% of this number remains undiagnosed. This means the vast majority of Australians who have Coeliac disease don’t yet know it – and this has massive implications.
So, here are the steps towards diagnosis:
- Genetics
- If you have a first-degree relative (parent, sibling, child) with coeliac disease you have about a 10% chance of also having the disease.
- HLA DQ2 and HLA DQ8 genes are associated with susceptibility to coeliac disease. We can easily test for them. BUT – while 50% of the population carry one or both of these genes, only 1 in 40 of these people will get the coeliac disease.
- So, genetics is about PREDISPOSITION – and not enough to confirm the diagnosis
- Blood test (serology)
- We can look for antibodies (tTGa-IgA and EMA) associated with coeliac disease. If you have these antibodies, you have a high risk of Coeliac disease and it is very likely that your intestinal villi have sustained a degree of damage.
- There is a catch though – to produce detectable levels of these antibodies you need to be eating a substantial amount of gluten. Many people with gut issues start avoiding gluten in an attempt to manage their symptoms. If this is your case, this test may not be valid.
- Endoscopy
- This procedure is the ‘gold standard’ for the diagnosis of coeliac disease and the aim is to confirm that there is damage to the intestinal villi.
- However, this procedure can only give accurate results if there is significant exposure to gluten for a minimum of 2 weeks prior to endoscopy. Remember – if there is no gluten exposure, we cannot look for glute-related damage.
Environmental factors play an important role in triggering the coeliac disease. Here are some of them:
- Exposure to high quantities of gluten
- Exposure to glyphosate, a herbicide that is very disruptive to the microbiome and associated with an increase in intestinal permeability
- Some intestinal viral infections, including rotavirus
- There is a strong relationship between dysbiosis (disruption in the microbiome) and Coeliac disease
What is the difference between gluten sensitivity and Coeliac Disease?
Have you been told that you do not have Coeliac Disease but you still feel that you react to gluten? Your doctor has said to go ahead and have your bread and pasta but each time you do, you end up bloated and puffy, your joints are aching and your skin breaks out. You CAN be sensitive to gluten, or wheat, without having Coeliac disease which is defined by damaged villi.
People with Non-Coeliac Gluten Sensitivity (NCGS) do react to gluten – just in a different way. In response to gluten exposure, they have increased levels of Zonulin, a protein that plays a very important role in regulating intestinal permeability. The intestinal lining is made up of a one-cell thick layer and these cells are ‘laced up’ together by structures called tight junctions. Zonulin sends a signal to ‘loosen up the laces’, thus increasing intestinal permeability. As a result, molecules that are not normally able to pass through the intestinal barrier sneak through and activate the immune system. This sets off a chain of events leading to inflammation which you may feel as a range of symptoms. Depending on your underlying susceptibilities this can be worsening of other autoimmune conditions, aching joints, itchy skin, worsening mood or a range of other symptoms.
If intestinal permeability is so important, what can we do?
First of all – we can measure intestinal permeability. There are 2 main methods.
- Zonulin
- Increased Zonulin, detected in stool, is a good indicator of increased intestinal permeability. Along with calprotectin, another stool biomarker, it can even be used to monitor and predict flares of inflammatory bowel disease. However, it should be noted that the Zonulin test can be less accurate in thin individuals.
- Mannitol / Lactulose test
- Mannitol is a small molecule, it passes easily through small gaps between ‘laced up’ cells of the intestinal lining
- Lactulose is a large molecule and cannot pass through a normal gut barrier
- When you consume both mannitol and lactulose, we expect to detect mannitol in your urine. However, lactulose should be trapped inside your gut. If lactulose passes through and is detected in the urine, it means that you have increased intestinal permeability, your gut barrier is not able to hold lactulose in and it is passing into your bloodstream and, eventually, into your urine.
Next, to regulate intestinal permeability, we need to ensure that the cells comprising the gut lining are looked after. We need to provide some of the essential nutrients for their function, but the most important thing is to ensure that we look after the microbiome.
Key nutrients for the function of the gut barrier, modulation of intestinal immunity and interaction with the microbiome are:
- Glutamine
- Vitamin D
- Vitamin A
- Zinc
- Short Chain Fatty Acids (produced by the microbiome)
The microbiome, composed of 50 trillion bacteria that live inside our gut, is in constant ‘conversation’ with our body and is essential for the regulation of intestinal permeability. Here are some members of the microbiome that play key roles:
- Lactobacillus rhamnosus, Bifidobacterium lactis and Bifidobacterium longum regulate ‘lacing’ between the intestinal cells
- Akkremansia muciniphila can help reduce ‘leakage’ of other microbes across the intestinal barrier
- Faecalibacterium prausnitzii and its metabolites help maintain a healthy and diverse microbiome. F. prausnitzii also has an anti-inflammatory effect and is considered to have therapeutic potential for the treatment of Inflammatory Bowel Disease.
But this is not all. The influence of microbiome on our overall health cannot be underestimated.
Here are a few examples of how it interacts with other aspects of our lives:
- The microbiome produces more serotonin than our brain. This serotonin then gets metabolised into melatonin. This means that your microbiome has a huge influence both on your mood and on your sleep
- The gut microbiome has an impact on nutrient metabolism, the host’s ability to extract calories from food and energy expenditure. Research has shown that supplementation with probiotics and prebiotics may alter the secretion of hormones, neurotransmitters, and inflammatory factors, thus preventing food intake triggers that lead to weight gain.
- A healthy microbiome, rich in Akkremansia muciniphila, is able to use polyphenols from pomegranate to produce a substance called Urolithin A. This compound has been shown to improve mitochondrial function, leading to improvements in muscle strength and exercise performance in middle aged adults.
Are you are wondering if you have Coeliac Disease or perhaps gluten sensitivity? Do you suspect that your microbiome might be influencing other areas of your health? Would you like to have some advice on how to support a healthy and diverse microbiome and ensure future good health? Get in touch with us.
