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Digestion & Autoimmunity

Dr. Jillian Sarno Teta

Chances are, you know someone that has been diagnosed with an autoimmune condition, or, you yourself have been diagnosed with one. Autoimmune diseases are a unique class of illness in that their hallmark is the immune system attacks the body. In autoimmune conditions, you attack yourself. This sounds counter-intuitive for survival, and sufferers of autoimmune disease would agree. So why does autoimmunity develop? What can we learn from it? Is there anything that we can do to treat and even prevent autoimmunity from developing? The exploration of these questions yields some interesting answers.

We know that in celiac disease, the immune system targets the lining of the small intestine for attack. In rheumatoid arthritis (RA), the immune system attacks the synovial fluid of the joints. With systemic lupus erythematosus (SLE), the immune system targets its own tissues; in multiple sclerosis (MS), the myelin sheath of the nervous system is attacked. In people with autoimmune thyroid disease, the immune system attacks the thyroid. This is by no means an exhaustive list of autoimmune conditions, but hopefully you get the picture.

We also know that autoimmune conditions like to run in packs. Where there is one, you are likely to find another. As an example, autoimmunity occurs in about 3% of the general population. However, additional autoimmune conditions occur in 30% of people with celiac disease. This is an enormous increase. Researchers have been trying to figure out specific mechanisms to explain why this occurs. It is easily and readily observable, yet not as easily explainable.

Until now. Though the picture is by no means complete, the work of researchers, clinicians and doctors is laying a framework of understanding for the mechanisms underpinning autoimmunity. Of particular interest is the work of Dr. Alessio Fasano, a physician and researcher at the University of Maryland who conducts research on celiac disease. He and his team have uncovered some very interesting trends in celiac disease that can actually be applied to other autoimmune conditions. This raises the exciting possibility that treatment approaches to celiac disease may benefit other autoimmune conditions as well.

The Autoimmune Triad

The work of Dr. Fasano has confirmed that in celiac disease, 3 factors have to be present for the disorder to manifest and present itself: a trigger, a genetic susceptibility and a hyperpermeable small intestine, or a “leaky gut”.

First, an environmental trigger must be there. In the case of celiac disease, the trigger is gluten, the protein that is found in wheat, barley, rye and products made with them. In other autoimmune conditions, the trigger could be a food allergy/sensitivity or it could be an illness, infection, trauma or even major life changes like divorce or death of a loved one.

Next, one must be appropriately genetically predisposed. We tend to think that genetics are the “be-all and end-all” of our health, body composition and even behavior, but this is far from the truth. Genetics play a role, but not the main defining one. People with celiac disease have inherited a set of genes that encodes particular proteins that makes them more sensitive to gluten.

Without getting overly technical, these genes code for particular histocompatibility leukocyte antigens (HLA). HLA proteins are made by cells in the immune system that are called antigen-presenting cells. These cells find foreign particles (anything that is not “self” is an antigen), cut them up into small proteins, fit these proteins on an HLA groove very much like a lock and key, and then these cells go and show other immune cells these HLA complexes. These cells then call in for the rest of the immune system, and an inflammatory cascade is generated.

In the case of people with celiac disease, they have the DQ2 or DQ8 version of the HLA gene and proteins – making their immune system primed to react to gluten. Additionally, people with celiac disease also tend to over produce the chemical messenger IL-15, which further stimulates the immune system. Other autoimmune conditions are also associated with particular HLA-DQ subtypes, some overlapping with celiac and others not. Interestingly, autoimmune thyroiditis shares overlap with celiac disease.

Finally, in people with celiac disease and even people without celiac disease suffering from other autoimmune conditions, there is the so-called leaky gut. The concept of the leaky gut was initially met with a great deal of skepticism from the conventional medical community, but thanks to the pioneering work of Dr. Fasano and others, that skepticism is turning into an embrace of the concept and a search for the answers to help people with leaky gut.

In a normal small intestine, the cells that line the inner portion stand next to each other, linked by “tight junctions”. Tight junctions, as the name implies, are very small, tight spaces in between cells. In people with celiac disease and other autoimmune conditions, those tight junctions loosen and separate, creating an abnormally large space between the cells. This, in turn, allows gluten and other food particles to enter the body and have direct contact with the immune system, bypassing normal routes of absorption. As you can predict, this contact activates the immune system and creates an inflammatory response.

What makes those tight junctions loosen? Several things can actually contribute to or cause this. Our immune cells themselves, in response to inappropriate foods, can loosen the junctions, as can dysbiosis in the normal gut flora. Infections of the gut and excessive antibiotic use can also contribute. These factors seem unpredictable. What if one never has a gut infection? People with celiac disease and other autoimmune conditions over-produce a protein called zonulin. Guess what zonulin does? You guessed it – it loosens tight junctions!

So, one needs increased intestinal permeability for those trigger-creating foods to interact with the immune cells which are genetically sensitized to react to said foods and wreak havoc on the system. Whew! All of these factors must be in place, so if one factor can be removed, can we not greatly blunt the development of autoimmunity?

In the case of celiac disease, the answer is a resounding yes. The removal of gluten from the diet stops the disease process in its tracks.

Applying Our Lessons

If we frame autoimmune diseases in the context that in order for them to manifest, several criteria have to be met – rather than just springing up randomly or because they “run in the family” – very compelling treatment options can begin to come to light.

Research is underway looking at aspects of vaccination, molecule blockers, zonulin blockers, immune modulating agents and a plethora of drugs for the treatment of celiac disease and other autoimmune conditions.

For the purpose of this article, however, it is extremely intriguing to have a look at what you can do in your own life, in your own home, to help yourself and your neighbors.

The kitchen is truly the best place to begin. The foods that we eat (and don’t eat, for that matter) play a huge role in how we look and feel. People with autoimmune conditions, including celiac disease, have unique nutritional needs. For starters, due to the nature of their over-active immune systems, they have a higher requirement for antioxidants than the normal population.

Antioxidants are found in abundance in fresh vegetables and fruits, green tea and cocoa powder. Consuming a diet high in vegetables and fruits – greater than 5-8 servings a day – is a sure way to get your antioxidants in. Choose vegetables in a variety of colors for optimum intake. The red, black, blue and purple fruits and berries are also antioxidant powerhouses. For your fruits, try to stay with those that have a lower glycemic index like berries, cherries, apples, pears, pomegranates and grapefruit over the higher glycemic index fruits like the tropical fruits and grapes.

Based on what we have learned in this paper, it makes good sense for people with autoimmune disease to avoid gluten and gluten containing products as best they can. Many people may be left wondering what there is left to eat, since gluten is so ubiquitous in our food. The foods that are left to eat are actually some of the healthiest, most biologically appropriate foods there are: veggies, fruits, tubers, proteins, nuts and seeds, and healthy fats. That, and a whole lot of gluten-free items like pasta, breads and baked gods. But a word of caution here. Gluten displaces the foods that we used to eat before it was easy to eat, foods we ate before the Agricultural Revolution, foods we ate before two thirds of us became overweight or obese. When we eat to many processed, baked goods – gluten-free or not – we are not eating those healthy foods mentioned above.

People with autoimmune conditions should be on a hypoallergenic diet, a diet that is going to cause minimal immune response and inflammation. This type of diet is one that is largely comprised of “real” foods – again, those foods listed above – and quite sparse in the department of sugar, grains and dairy products. There is a class of vegetables called the nightshades, consisting of tomatoes, bell peppers, eggplant and white potatoes that have been shown to increase intestinal permeability in people with autoimmune disease, and these foods should be cut back as well.

So, fill your plate up with veggies, lean proteins like chicken and turkey breast, beef or pork tenderloin, perhaps a sweet potato, with a cup of berries topped with coconut cream for dessert, and you will be well on your way!

Hydration is another major, though often overlooked factor. Water is the ultimate solvent, meaning it can dissolve many, many things. Adequate hydration status can actually help to dilute some of those inflammatory markers. Do not underestimate its power! You want to aim for half of your body weight, in ounces of water daily. Example: If you weigh 200lbs, aim for 100 ounces of water daily.

Exercise, particularly burst training and resistance training, increases blood flow and circulation, helping further to flush out inflammatory molecules. More importantly, resistance and interval training stimulate release of human growth hormone, a powerful anti-inflammatory, pro-healing hormone. If you do not exercise, now is the time to start looking into a program.

Tissue specific support can also go a long way towards helping you feel better. People with celiac disease would do well on a program of gut-supportive nutrients; likewise, someone with thyroid disease can use nutrients to supplement their thyroid, and so on. As a general rule, since we know that for autoimmunity to be present, there has to be that trinity of trigger, genetic susceptibility and a leaky gut, treating the gut is always going to be a good idea.

Final Thoughts

Celiac disease is an amazing model for many other autoimmune conditions and many lessons can be gleaned from not just the pathophysiology of the disease itself, but of treatment and hope for other autoimmune conditions. As these shared commonalities are further elucidated, more and more treatment options will become available, including dietary and lifestyle intervention. Never underestimate the power of your food, your actions and the way you live your life in the development of your own health.