By Anita Bermann, MS, Bastyr University Dietetic Intern
Originally published in Celebrate Gluten-Free Magazine, Winter 2015
You thought you had the gluten-free diet down. You expanded your diet beyond meat and bananas; you found gluten-free bread that doesn’t taste like cardboard, learned how to incorporate weird ingredients like tapioca and xanthan gum into your holiday baking, and most importantly of all, are feeling much better. The world has felt friendlier in the days since your diagnosis: whenever you have a craving, whether for pizza, cake, or beer, a gluten-free product is finally there to fill it. All in all, you’re doing well, and indeed, you’ve come a long way. Following a gluten-free diet, reading all those labels, fighting all those crumbly breads, can certainly be hard work but you’re getting it figured out.
But. For some reason, even though you’re doing everything right, you may not feel completely well, completely normal. If you are like many patients with celiac disease, you might have some persistent symptoms that could range from annoying to debilitating. Maybe you still experience frequent gas and bloating, or irritable bowel symptoms like constipation and diarrhea. Perhaps you’ve discovered that you are more prone to infections than those around you, or more exhausted, or some other mystifying complex of symptoms. Maybe your intestinal biopsy still shows signs of inflammation despite years on a gluten-free diet.
When you talk to your primary care doctor about this, he or she may suggest that somehow gluten is continuing to get into your diet, even though you know that’s not the case. Or maybe you’re just told there’s nothing more you can do, because the gluten-free diet is the only treatment for celiac disease. Is it all in your head? Is it hopeless? There’s got to be something else to try, you think.
Yes, there is more you can do that may help heal your gut and re-align your immune system after a diagnosis of celiac disease. Although research doesn’t have all the answers yet, scientists are beginning to discover that treatment for celiac disease may not stop at a simple gluten-free diet. Avoiding all gluten-containing foods and foods cross-contaminated with gluten is the gold standard for treatment, but in order to support long term health, many celiac disease patients may benefit by also addressing a few other lingering issues, namely: leaky gut, dysbiosis, and inflammation.
In order to understand what’s happening, let’s review some celiac disease physiology:
Down in the Small Intestine
Our digestive system is not only a way to absorb beneficial nutrients into the body; it is also an active player in the body’s immune system. Because this hollow tube is open to the outside world, it is our first line of defense against foreign invaders like viruses and toxins. The whole system relies on adjustable gaps between the intestinal cells (enterocytes) called “tight junctions.” By opening and closing selectively, tight junctions regulate what we allow past our defenses and into the bloodstream. The idea is that toxic foreign invaders will be kept on the outside, and good nutrients let in.
Unfortunately, this system is delicate and doesn’t work perfectly in everyone. Sometimes the tight junctions open too wide, allowing bad things in, including pathogens and undigested food particles that are too large for our body to process. When this happens, we refer to it as increased intestinal permeability, or “leaky gut syndrome.” Leaky gut causes the body to recognize food particles as invaders and results in persistent inflammation and subsequent damage to tissues. Leaky gut syndrome has been associated with celiac disease, as well as other autoimmune disorders like type I diabetes, rheumatoid arthritis, and irritable bowel disease. When your gut is leaking, your entire immune system is out of balance, and a range of problems is possible.
Let’s look at how this happens in the context of celiac disease:
- For patients with celiac disease, gluten is indigestible. The gluten found in wheat, rye, and barley contains certain protein strands called prolamines (i.e. gliadin in wheat, hordein in barley, and secalin in rye, but we’ll use gliadin to refer to all in this article) that we don’t have the enzymes to process. The intestinal cells of individuals with celiac disease view the gliadin as an invader.
- When gliadin interacts with the intestinal cells, they release chemicals (called inflammatory mediators) to ramp up the immune response and try to fight the invasion. This means that white blood cells start rushing out of the bloodstream towards the fight in the gut.
- Meanwhile, gluten also increases levels of an intestinal compound called zonulin. This recently discovered alien-sounding particle is responsible for regulation of intestinal permeability. Higher levels, found in celiac disease and other autoimmune disorders, mean wider gaps between the intestinal cells.
- So now we have an undigested particle facing a wide open gate between tight junctions. And through the gate is exactly where the gluten particle goes. This is called “paracellular translocation,” which basically means that the enemy is inside the walls, i.e., the gut tissue. The immune system isn’t programmed to deal with food particles here, and it goes into overdrive, releasing even higher numbers of white blood cells as well as inflammatory mediators that cause the tight junctions to open even further.
- The white blood cells and inflammatory mediators involved in the fight release toxic chemicals that damage not only the foreign particles but also the gut tissue itself. The villi on the outside of the enterocytes that we use to absorb nutrients get the brunt of the attack, and are worn down to stubs.
- In the end, the result of the gluten ingestion is damaged tissue and malabsorption, often accompanied by the familiar cramping, diarrhea, and bloating symptoms, as well as lingering leaky gut syndrome.
Researchers led by Alessio Fasano of the Center for Celiac Research and Treatment at Massachusetts General Hospital have found that three things are required to develop celiac disease: ingestion of an environmental trigger (gluten), genetic predisposition (HLA DQ2/DQ8 genes), and increased intestinal permeability.
This last finding is a key development in the understanding of celiac disease. Intestinal permeability doesn’t only worsen in celiac disease, it partially causes celiac disease. Patients with celiac and other autoimmune diseases have a predisposition to a leaky gut. This could explain in part why autoimmune diseases sometimes occur together. Whether this is because of higher zonulin levels, or pre-existing inflammation, or something else, we aren’t sure, but we do know that stopping the leakiness is an important factor to consider.
Conventional celiac disease wisdom says that once gluten has been removed from the diet, zonulin levels will normalize, the immune system will calm down, and tight junctions will close, returning a patient to health. In practice, however, this doesn’t always happen.
Inflammation Can Linger for Years
Studies have shown wide variability in healing of gut tissue after a diagnosis of celiac disease. By some estimates, 60% of adults never completely heal, despite following a gluten-free diet. One study showed complete small intestine recovery in only 34% of patients following a gluten-free diet for two years. Many studies show some amount of persistent white blood cell infiltration, the hallmark of inflammation, as well as higher levels of inflammatory chemicals, even years later. Celiac disease patients tend to have higher levels of zonulin and greater gut leakiness than people without celiac disease, whether eating a gluten-free diet or not.
Apparently, it’s harder than we thought for the body to recover from immune and inflammatory imbalance in the gut, and some people may be pre-disposed to have a harder time of it. But in order to truly understand the problem, we must discuss one more condition: dysbiosis.
Let’s Talk About Bacteria
Remember the entire inflammatory cascade caused by gluten that we discussed above? There’s another thing that can also have a significant effect on opening tight junctions, and that’s bacteria. When levels of bad (pathogenic) bacteria overgrow in the small intestine (referred to as either dysbiosis or small intestine bacterial overgrowth [SIBO]), this can trigger zonulin release and lead to leaky gut syndrome. The body is trying to open the gates to let white blood fighter cells out to attack the bacteria, but meanwhile, food particles can pass through, causing tissue damage and triggering an auto-immune response in some people.
Researchers have found a high incidence of dysbiosis in both symptomatic and “recovered” celiac patients, to the point that it looks like overgrowth of bad bacteria and leaky gut seem often to go hand in hand in initiating and continuing symptoms in celiac and other autoimmune disease patients. In one study, biopsies from children with celiac disease showed overgrowth of thirty types of bacteria not found in the intestine before. Other studies have shown lower levels of the healthy Bifidobacteria and overall diminished biodiversity among good bacteria, making it easier for bad bacteria to overgrow.
When bacterial imbalance occurs in the small intestine, toxic byproducts from the bad bacteria irritate the intestinal cells, causing damage that worsens leaky gut. The bad bacteria also feed on undigested carbohydrates (they love sugar), releasing high levels of gas like hydrogen and methane. This can result in bloating, diarrhea, and constipation.
Bacterial imbalance is becoming more common in everyone, due to the preponderance of refined starches in the standard American diet, environmental toxins, lack of fermented foods, and, ironically, better hygiene practices.* However, it is usually found in much higher numbers in patients with celiac disease, even after gluten withdrawal.
*Note: the “hygiene hypothesis” says that there is a correlation between people who live in “sanitary” countries (with low incidence of childhood infection and parasites from dirt) and higher levels of autoimmune disease. Researchers think that one possible explanation is that our immune systems need to be “trained” by these invaders to differentiate a true threat from our own bodies.
So even years after becoming gluten-free, many people with celiac disease show a tendency to struggle with dysbiosis, leaky gut, and lingering inflammation, with all the side effects and future pathologies this may involve.
The important thing, then, is to consume a healthy gluten-free diet that will help to relieve these problems. Unfortunately, the gluten-free diet followed by many patients with celiac disease is just the opposite.
How the Gluten-Free Diet Can Worsen Inflammation, Dysbiosis, and Leaky Gut
The gluten-free diet may be the gold standard, but for many patients, its implementation results in less than treasured results.
For one thing, many gluten-free grain products are higher in sugar and simple starch than their gluten-containing counterparts. Gluten-free goods often need extra sugar to make them taste good or bake properly, and common gluten-free grains are often less nutritious than wheat. Too much sugar can feed bad bacteria and worsen gut inflammation.
Let’s compare whole wheat and rice. Whole wheat is higher in protein, fiber and minerals than many gluten-free grains. For example, two slices of whole wheat bread contain about 8 g protein, 7 g fiber, 1 mg iron, and 30 percent of your daily value for thiamin (a B-vitamin needed for energy). Conversely, a half-cup serving of brown rice contains only about 3 g protein, 2 g fiber, 10 percent of your daily value for thiamin, and a trace amount of iron.
All grains lose vitamins, minerals, protein and fiber when the outer hull is removed in refining, but rice and corn lose more than wheat. White rice flour has scant protein, while all-purpose wheat flour still contains 6 g per half-cup. Wheat Chex, for example, has 6 g fiber and 5 g protein per serving, while Rice Chex only contains 1 g fiber and 2 g protein. Wheat flour products are often enriched after refining, which means iron and crucial B-vitamins like folate, niacin and thiamin are restored. This doesn’t always happen for gluten-free products, which leaves many deficient in certain nutrients and high in simple carbohydrates.
In addition, many patients with celiac disease just don’t eat the recommended amount of whole grains. One study found that 38% of meal intake by people with celiac disease may not include grains, which could lead to inadequate fiber, iron, folate, niacin, and zinc intake. In fact, another study showed that about half of celiac patients on a gluten-free diet show signs of poor vitamin status. Folate, iron, B-vitamin, potassium, magnesium, calcium, zinc, and vitamin D deficiencies are especially common in celiac patients.
The upshot of all this is worsened dysbiosis (the lack of fiber especially plays a role), which in turn worsens inflammation. One study found that people fed a refined gluten-free diet experienced a decrease in healthy and increase in unhealthy gut bacteria after only one month.
So, in order to optimize health, diet should go beyond gluten-free. Celiac patients should strive to eat in a way that provides ample nutrition, reduces inflammation, reduces pathogenic bacterial overgrowth, and as a result, addresses gut leakiness.
A Healthy Gluten-Free Diet:
A smart gluten-free diet focuses on whole foods rich in fiber, protein, vitamins and minerals. This means ample servings of real whole grains and smaller amounts of high sugar dysbiosis-promoting refined and processed substitute products. Choose a variety of grains like amaranth, buckwheat, wild rice, quinoa, millet, teff, and brown rice, and rotate your grains to ensure a balance of nutrients. Be careful to choose gluten-free grains that have not been cross-contaminated, to ensure that you don’t aggravate your gut immune system further. If you plan well, you can end up with even more fiber and minerals than when eating a gluten-containing diet. For example, amaranth and quinoa are high in protein and can contain 9 g and 5 g fiber per half-cup, respectively, as well as B-vitamins. Don’t forget about nuts, beans, fruits, and vegetables, which are also high in fiber, vitamins, and minerals to help your gut heal. Sea vegetables are especially useful, because of the high proportion of iron, potassium, and other minerals, as is broth made from animal bones (see recipe p. 52)
Some people find additional benefits in soaking gluten-free grains overnight. Soaking before cooking can help make the grains more digestible and render minerals more bio-available.
In addition to food, celiac patients often need supplementation because of the continued difficulty in absorption. Ask your doctor to check iron, vitamin D, bone density, and B-vitamin measurements to make sure a few additional vitamins and minerals aren’t necessary. Vitamin D is especially important in ensuring that the immune system functions normally without excessive inflammation.
Even with a balanced diet, however, most people with celiac disease may benefit by going further to address dysbiosis and inflammation.
Beyond the Basics Part 1:
Cultivate Healthy Gut Bacteria
The first step to cultivating a healthy bacterial population that supports closing of tight junctions is to minimize foods that increase bad bacteria: gluten of course, but also refined sugar, food additives in processed foods, and for some people FODMAPs, certain short chain carbohydrates that can be poorly digested and thus become food for bad bacteria.* The second step is to eat the whole foods, high fiber diet described above at least 80% of the time, which provides the fuel for good bacteria to grow.
*For more on FODMAP foods, see the GIG educational bulletin entitled “The Low FODMAP Diet” at www.gluten.org.
Beyond this, probiotic foods and supplements might be helpful. Research is not conclusive in the area of probiotics as an adjunctive treatment in celiac patients, but preliminary results look promising. Bifidobacterium lactis, one probiotic strain, for example, has been shown to inhibit gut leakiness, as have some Lactobaccilus strains. In one study, 93% of children had faster remission of gut inflammation symptoms with probiotic treatment.
Not enough is known to customize a probiotic supplement for celiac disease, but natural probiotic sources like sauerkraut, kimchi, kefir, sourdough, miso, tempeh, and kombucha contain a wide enough variety of bacterial strains that you’re likely to ingest a helpful one when consuming wild-fermented foods. In one study of gluten-free sourdough bread, for example, the sourdough fermentation was shown to produce Bifidobacteria that have been shown to help reduce gut inflammation.
Including probiotic foods and/or supplements in a balanced gluten-free diet may help increase the speed and depth of healing from celiac damage.
Beyond the Basics 2: Combat Inflammation
Probably the most important thing a person with celiac disease can do, besides avoid gluten, is to pick a diet that is as naturally anti-inflammatory as possible. This will help the white blood cells and inflammatory mediators leave the gut tissues and return to the bloodstream, ceasing their damaging attack. This will also help close tight junctions, which can help pretty much any autoimmune or inflammatory condition. Luckily, everything discussed previously—choosing whole grains, ensuring adequate intake of all vitamins, minerals, and fiber, as well as re-growth of beneficial intestinal bacteria—already has an anti-inflammatory effect on our gut.
There are a few important steps to take the anti-inflammatory benefits further, however:
The most important is to strive for 7-10 servings of fruits and vegetables a day. Fruits and vegetables are considered cooling to inflammation because they contain a rainbow of phytochemicals that can down-regulate the inflammatory response. Green leafy vegetables, cabbage family vegetables (brassicas), berries, cherries, pomegranates, garlic and onions are particularly rich in these beneficial compounds. Herbs and spices can contain concentrated forms of some of the same compounds as fruits and vegetables, so don’t forget to spice it up! Garlic, ginger, turmeric, rosemary, thyme, cinnamon, dill, and basil are a few options with known anti-inflammatory effects.
Choosing omega-3 fat sources is also important. Omega-3’s are considered the “anti-inflammatory” fats because they turn off inflammatory signaling molecules. This is in opposition to omega-6 fats, which can increase inflammation when eaten in excess. Cold water fish, grass-fed meat, walnuts, extra virgin olive oil, flaxseed, and fish oil supplements are all great sources of omega-3’s. Try to avoid excessive amounts of corn, soybean, safflower, and sunflower oils, the omega-6 dominant fats. Avoid hydrogenated (trans) fats as much as possible, as they are extremely inflammatory.
When choosing a drink in addition to water, choose tea whenever possible. Herbal as well as black, green, and white teas have high levels of anti-inflammatory polyphenols. Alcohol is fine in moderation (usually 1 glass/day for women and 2 for men, with red wine a better choice because of polyphenols in the grapes) but too much alcohol is highly inflammatory.
For cooks ready to go a step further, making your own bone broth could help heal gut mucosa damaged by inflammation. Bone broth is an ancient healing food: it is simply animal bones boiled in water for 12-48 hours until they soften and release minerals and collagen. Collagen is very easy to digest and bone broth also contains minerals like calcium and magnesium to help nourish the body with the nutrition it needs. Sub-clinical magnesium deficiency, for example has been linked to higher levels of circulating inflammatory molecules in the body.
Finally, reducing inflammation goes beyond diet. One of the most potent triggers of inflammation that we haven’t discussed yet is stress. Stress can cause an increase in pathogenic bacteria, which can worsen leaky gut, and can also increase the levels of damaging inflammatory molecules. The brain-gut connection is particularly well-developed, and stress hormones released by the neurological system cause immediate inflammatory changes in the gut. Daily stress reduction techniques are key to calming the gut as well as the brain. Find a practice that works for you: yoga, meditation, walking, biofeedback, etc., and try to make time in the day for stress reduction no matter how busy you are.
Healing the damage from celiac disease and restoring the immune system back to a state of normalcy may improve many lingering symptoms in those with celiac disease. It is not a quick process, but with a truly healthy gluten-free diet, it is possible. Choose one diet change from the list below, and make it a habit before moving on to the next, taking one step at a time towards lasting wellness.
As you can see, healing a gut damaged by celiac disease goes beyond simply choosing a gluten-free diet. The major recommendations discussed in this article include:
- Increase high fiber, high vitamin-and-mineral-containing fruits, vegetables, and gluten-free whole grains to support the growth of good bacteria and turn off inflammatory molecules.
- Minimize refined grains, sugars, and processed gluten-free products that can feed bad bacteria and worsen dysbiosis.
- Include naturally fermented foods and probiotic sources like miso, kimchi, kombucha, kefir, sauerkraut, or supplements in your diet to support the growth of good bacteria.
- Aim for a rainbow of 7-10 servings of fruits and vegetables (that’s ½ cup cooked or 1 cup raw per serving) a day to cool inflammation.
- Spice up your life! Herbs and spices help to cool inflammation further. Garlic, ginger, turmeric, rosemary, thyme, cinnamon, dill, and basil are a few great choices.
- Choose anti-inflammatory fat sources such as fish oil, walnuts, flax, and olive-oil whenever possible.
- Try anti-inflammatory liquids like tea and bone broth.
- Practice stress-reduction techniques to calm pathogenic bacterial overgrowth.
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Anti-Inflammatory Rainbow Power Slaw
Original recipe by Anita Bermann, 2014.
This salad will make you feel like a million bucks! Make a big batch and eat it with meals all week long.
½ small red cabbage, thinly sliced
½ small green or Napa cabbage, thinly sliced
1 head broccoli or ½ head each broccoli and cauliflower, cut into bite-sized florets
2-3 carrots, shredded (use purple carrots if you can find them!)
1 red, yellow, or orange bell pepper, cut into thin slices
1 tablespoon minced fresh ginger
½ teaspoon dried ginger
2 tablespoons grated fresh turmeric root, or 1 tablespoon dried
2 avocados, cubed
1 large mango, cubed
¼ cup dried goji berries (fresh or dried blackberries make a good substitute if you can’t find these)
1 cup walnuts, chopped
¼-½ cup sesame and/or sunflower seeds
2 tablespoons sesame oil
¼ cup+ olive oil
¼ cup+ apple cider vinegar (use raw vinegar if you can find it)
Salt and pepper, to taste
Combine ingredients through sesame seeds in a large bowl. In a separate container, mix together oils and vinegar, and then gently toss into slaw. Drizzle more olive oil and/or vinegar on top of slaw and gently mix in if you desire a moister consistency. Add salt and pepper to taste.
Preparation time: 45 minutes
Quinoa and Kimchi Breakfast Bowl
Original recipe by Anita Bermann, 2014.
This tasty and nutrient-rich combination is a satisfying way to start any morning. Red quinoa adds color and flavor, but white has a similar nutrient profile and will work fine.
½ cup cooked red quinoa (¼ cup dry will make about ½ cup cooked, soak overnight to increase nutrient availability)
1 poached or fried egg
½ cup kimchi or sauerkraut
1 green onion, thinly sliced
½ avocado, cut into thick slices
Salt, pepper, and butter to taste
Layer ingredients in a bowl in a way that looks beautiful and appetizing to you. Enjoy!
Preparation time: 5 minutes if quinoa is pre-cooked
Kimchi Cream Cheese Spread
Recipe adapted by Anita Bermann from Firefly Kitchens, www.fireflykitchens.com/blog, 2013
This dip is creamy, tart, and spicy all at the same time! Try it in the center of your next vegetable appetizer tray.
½ cup kimchi + brine to thin as needed (Firefly brand kimchi
1 box cream cheese
2-4 tablespoons soft goat cheese (optional)
Combine all ingredients in a food processor and process until smooth. Add extra brine if a thinner consistency is desired.
Smoky Ginger Butternut Seaweed Soup
Copyright 2013, A. Bermann, Original recipe (first printed in Northwest Prime Time magazine, September 2013)
Iron rich dried dulse seaweed imparts a subtle smokiness to this creamy soup, while a broth made with kombu adds minerals.
1 2-pound butternut squash
2 tablespoons olive oil
4 garlic cloves, minced
1 onion, thinly sliced
1 tablespoon minced fresh ginger
1 sweet potato, diced (about 2 cups)
1 4-inch piece dried kombu or kelp
5 cups bone broth or water or a mixture
¾ cup apple cider or juice
½ teaspoon cinnamon
1 teaspoon dried dulse flakes
Salt and pepper, to taste
Crème fraiche, to serve (optional)
Preheat oven to 375°F. Cut the squash in half and remove the seeds, place halves on oiled baking sheet and bake until tender, about 45 minutes.
Warm oil in a 4-quart soup pot over medium-low heat. Add the garlic, onion, and ginger; sauté until the onions are golden, about 10 minutes.
Add the sweet potato, kombu, and stock. Cover and bring the soup to a boil, then reduce heat and simmer until sweet potatoes are soft, about 15 minutes. Discard the kombu.
Scoop flesh from cooked squash into soup, add apple cider, and puree until smooth using a blender. Return the soup to stove over medium-low heat.
Stir in cinnamon, dulse, salt and pepper. Serve hot with a swirl of crème fraiche and sprinkle of cinnamon.
Preparation time: 1 hour
Yield: four 2 cup servings
Super Kefir Cranberry-Ginger-Pumpkin Smoothie
Original recipe by Anita Bermann, 2014
Start your day off right with a burst of probiotics and anti-inflammatory berry power! Kefir can be found in the dairy section of most natural food stores.
¾ cup unsweetened kefir (fermented dairy or coconut milk)
½ cup plain whole milk yogurt (or use more coconut milk kefir to make dairy-free)
1 cup mixed berries of choice (blueberries, blackberries, raspberries, etc.)
½ cup frozen or fresh cranberries
½ cup plain cooked (canned is fine) pumpkin or butternut squash
1 tablespoon cinnamon or pumpkin pie spice
1/2 teaspoon minced fresh ginger, or ¼ teaspoon dried
½ cup walnuts (soak overnight to increase creaminess and digestibility)
Orange juice, apple cider, or filtered water as needed
Combine all ingredients in blender and pulse until creamy. Add juice or water if needed to create desired consistency.
Preparation time: 5 minutes