Gluten, Autoimmune Disease, and the Microbiome

This post explores some of the links between gluten consumption and autoimmune disease, and how they relate to Chinese medicine. In order to make this exploration, some initial connections need to be made between different theories about what causes certain forms of autoimmune disease.

Donna Jackson Nakazawa’s 2009 book The Autoimmune Epidemic explores the spread and severity of autoimmune conditions in recent decades, but it is more oriented towards case studies of individuals who struggled to get diagnoses when the phenomenon was still relatively new to doctors, and as such, does not focus so much on the research into causes and cures. It does, however, acknowledge the link between gastrointestinal health and autoimmune disease, and in particular, the notion of ‘leaky gut’ – a condition whereby the gut lining becomes permeable and allows substances to pass through it into the bloodstream – as a trigger.

A healthy intestine allows only digested nutrients to pass into the bloodstream. In patients with immune and inflammatory-based illnesses, the body’s intestinal lining often becomes impaired, thus permitting larger molecules, such as bacteria and undigested foods, to slip through. In the bloodstream, these foreign items can trigger an immune reaction, making the body think it’s under attack and prompting the body’s immune system to lash out to battle those foreign pathogens.[1]

From the standpoint of Chinese medicine theory, this description finds an analogy in Wei Qi (‘Wei’ means ‘to defend’) and external pathogenic factors, with the gut lining acting as the protective ‘Wei’ barrier around the gut which, when weakened, allows pathogens (in this case gluten toxicity) to pass through. Although Wei Qi is said to run ‘under the skin, in between the muscles’[2] on the outside of the body, if we think of the entire digestive system as a tube, connected at both the mouth and anus to the outside of the body, then perhaps we could extend our thinking about Wei Qi to include the digestive tract, which makes sense given that 70-80% of our immune system is said to reside in the gut.

Wei Qi is said to be, in part, ‘derived from the coarse part of food and water’, after it is refined and transported to the Lung. This gives us a very clear picture of the Chinese medicine organ pair alliance of the Lung and Large Intestine, and also an insight into why gut health is so intrinsic to a healthy immune system – if our food is not being digested properly, Wei Qi is not going to be created. It would also indicate LU7, the Lung channel luo-connecting point, as a potentially important point for those suffering symptoms of gluten intolerance. Not only is it the channel’s link to the Large Intestine, but it assists the Wei Qi in expelling pathogens from the exterior Wei level.

It is important to note that many nutritionists consider gluten – and all cereal grains – to be toxic, not just to those with autoimmune conditions, but to everyone.

Gluten is directly toxic to intestinal cells: it inhibits cell proliferation, increases cellular oxidation products, and changes membrane structure. In the body, gluten changes the structure of the intestine: it reduces the height of the villi, decreases the depth of crypts, and decreases enterocyte surface.[3]

Chris Kresser says these grains’ toxicity is a result of their long-term evolutionary efforts to protect themselves – by producing toxins, grains damage the human gut lining, bind minerals to make them less bioavailable, and inhibit their being digested.[4] But it is not just a matter of toxic buildup affecting digestion—it is the body’s attempt to rid itself of the toxins that leads to an immune response, as Paul Jaminet explains:

As all toxins do, gluten inspires an immune response. This immune response helps to clear the gluten from the intestine, preventing a build-up of toxins; however, in the process it makes the intestines inflamed. This inflammation kills intestinal cells and makes the gut leaky.[5]

In the case of leaky gut, the process of refining food and water to produce Wei Qi is not only impaired, but the Wei Qi barrier is also broken, by a toxin that is immediately able to make its way into the bloodstream and trigger an autoimmune response. It would be interesting therapeutically to experiment with the role of the Small Intestine in easing the symptoms of autoimmune patients, because in celiac patients, gluten ‘damage[s] the villi of the small intestine, causing the villi to flatten [which] results in the malabsorption of nutrients’.[6] Approaches could include asking the patient about their relationship to decision-making and mental clarity, in order to understand whether the SI’s control of ‘our capacity of discriminating between choices’ is being affected.[7] We usually think of the Liver when looking at patterns of anger and resentment, but these are also relevant to SI pathologies, and should be considered. There may also be a Kidney Yang component, which provides heat to fuel the SI in its job of separating food received from the Stomach into clear and turbid fluids.

Italian doctor and researcher Alessio Fasano explained this reaction in more detail as relating to a molecule called zonulin which regulates the permeability of the gut, and which is produced in excess by people who have celiac disease. Fasano compares the function of zonulin to a door opening and closing, explaining that, in a relatively healthy person, the door opens and closes quickly, allowing swift recovery of the intestinal barrier, whereas in the case of pathology as in with celiac patients, the door becomes ‘stuck open’.[8] Zonulin is produced naturally by the body in the case of bacterial build-up in the small intestine as a means of flushing the lumen with water and diluting the bacteria; but it is also produced when gluten is ingested. Fasano says that when gliadin (one of the two protein types that comprise gluten[9]) is introduced to the epithelial cells in the gut, it causes zonulin to be produced.[10] In someone who already has an autoimmune condition, this means that, when the toxins pass through the gut and enter the bloodstream, the body launches an immune response against itself. There are other factors than gluten involved in autoimmune conditions, however: Fasano’s research shows that celiac patients on a gluten-free diet still have zonulin levels up to thirty times higher than non-celiacs eating gluten.[11]

From a Chinese medicine perspective, this would indicate that the difference between a celiac patient, and one who can tolerate a certain amount of gluten without noticing any adverse effects, is Wei Qi. In the relatively healthy person, the protective barrier of the gut is able to immediately restore itself, whereas in the celiac patient, the Wei barrier is left open. But there are clearly factors other than gluten which are in play here.

In terms of the autoimmune disease psoriasis, which produces lesions on the skin, research indicates that there are key factors other than diet:

The University of Michigan carried out a study in 1991 which aimed to identify the genetic bases of psoriasis. The laboratory has found that psoriasis is a “complex disease” which may involve genetic, immunological and environmental factors. […] [R]esearch on families and identical twins who are suffering from psoriasis show there is a strong genetic component, although environmental factors, such as infections, stress, and injuries are also important (University of Michigan, 2005).[12]

It seems that this ‘strong genetic component’ may be incontrovertible in autoimmune conditions, but the external pathogenic factors of infection, stress, and pollution can be somewhat addressed through therapeutic practices.

I am particularly interested in the notion of the progression of gluten intolerance into autoimmune conditions. As a sufferer of psoriasis, I know that I can keep my symptoms under control through diet and self-care. My uncle has the same skin condition as I do, but in his case, it developed into rheumatoid arthritis. This is not merely an observation: a research study in 2012 found psoriasis patients to be more than 50% likely than non-psoriasis patients to have additional autoimmune diseases.[13] Psoriasis (yín xiè bìng) has a number of different diagnostic patterns in Chinese medicine because it manifests, climatically, very differently in different patients. Typical diagnoses include blood stasis, blood dryness, damp-heat, heat toxin, and Liver/Kidney deficiency, although I would posit that the deficient diagnoses have less to do with the actual root of the disease, and more to do with its debilitating effects on the Shen and the patient’s ability to handle self-care.[14] Li Lin’s book on treating psoriasis with TCM discusses the theory of Dr. Zhao Bingnan, who ‘pointed out that blood heat is the internal factor in [the] human body which is an important element in causing psoriasis’, and that the condition may be referred to as ‘domination of evil heat in the blood’.[15]

In terms of the four levels, I would propose that in severe autoimmune conditions, where there is blood heat and fire toxin, start at the Wei level, either in the gut or on the skin. A blog article by rheumatoid arthritis sufferer Jesse Golden caught my attention many months ago due to this description:

A Chinese doctor that I used to see informed me that there have been studies in China that give mice symptoms similar to Rheumatoid Arthritis by having them exercise while blowing cold air on them. What they found is it creates and infection in the body. The coincidence is that I grew up dancing everyday and then would go outside after sweating into very cold Chicago weather. I have also found this common denominator to be true of many athletes and others living with various forms of arthritis.[16]

The description caught my attention because, as a young girl living in London, I hated wind in the winter, because I was always someone who sweated easily. In cold weather, bundled up and walking around very quickly and moving in and out of heated public transport, my body was often drenched. I remember once writing in my journal as a teenager, ‘It’s the worst thing, to be sweating and freezing at the same time.’ In the terms stated by Golden’s doctor, the etiology of rheumatoid arthritis comes from a pathogen getting caught in the Wei level when the pores are open – in this case, cold – progressing more deeply into the Qi level, and from there eventually ending up in the blood level as heat, which is, of course, where we find one of the roots of the Wind that causes arthritis and the itching of psoriasis, and indeed the blood dryness and subsequent stagnation of other psoriasis diagnoses. Lin agrees:

The aetiology of psoriasis is caused by the external pathogenic wind at first. This wind attacks in the skin and turns into heat later down the track, leading to heat in the blood and dryness of blood or blood stasis.[17]

This etiology would also support the use of the Small Intestine channel for treating patients with autoimmune disease and symptoms related to gluten sensitivity, as one of its major functions is to expel internal and external Wind. (SI3 to tonify the Kidneys and expel Wind, SI8 in a damp-heat type psoriasis, SI12 (‘Watching Wind’) because of its link to the Large Intestine channel, and possibly SI14, because that is where the channel pathway descends into the Small Intestine organ.

In terms of thinking about whether or not an autoimmune condition may be developed through the long-term ingesting of gluten, we need to think of the intestines and their relation to the Qi levels. I have already discussed how and why we might think of the gut as part of the Wei level. If the first barrier to be broken in the gut is the Wei Qi level, it makes sense that patients with strong Wei Qi will see no symptoms from ingesting gluten, even though it is a toxin, because their immune response is able to kick the gluten pathogen out of the body to be excreted, and restore the Wei barrier. In a patient with autoimmune disease such as psoriasis, the toxin is allowed to permeate through the Wei level into the Qi level, Ying level, and Blood level. An article in The Atlantic from earlier this year about the links between rheumatoid arthritis and the microbiome (the microbes that live in the gut) referenced a study which found that rheumatoid arthritis sufferers were more likely to have the Prevotella copri bug in their intestines than others, and thus emphasized the role of external factors, including diet, in managing the condition.

[…] many microbiome researchers argue that at least some of [the rise in incidence of autoimmune disease] is due to changes in our bacterial ecosystem. Altered diet, the explosion of antibiotic use, and decreasing contact with the microbe-packed natural world of animals and plants have all combined to transform the bacteria that call humans home.[18]

Fasano agrees that the integrity of gut flora is what makes the difference between a person who can tolerate gluten and one who cannot. Speaking about the case of two women who developed autoimmune conditions in their 70s, he says:

[…] what happened to these ladies that after so many years lost that luxury and then switched from tolerance to an immune response?  And here, I believe that the most likely answer is the microbiome […].

What this suggests is that those who are genetically predisposed to autoimmune conditions may be able to find long-lasting relief from re-occurring symptoms, once flare-ups have been treated with appropriate herbs and diet, through careful attention to building, protecting, and maintaining their Wei Qi, both as it manifests through Lung Qi, and through gut health. The problem with this hypothesis is that, in the case of autoimmune diseases, a healthy immune system can work to a patient’s disadvantage because it has more energy with which to attack its host. I have heard other sufferers of psoriasis say that their skin rashes are often worst when they are eating well. This may be due to the component of blood health, and the implications for Spleen and Liver involvement – the Spleen in failing to provide enough Gu Qi to the Lungs, and the Liver Blood in lacking nourishment and fluidity. But I do believe that, in the long-term, even if it is not possible to ensure that the diseases are completely disarmed, it is possible to minimize the damage that they do to the body, and to restore some semblance of balance – particularly if, as the research in this paper suggests, autoimmune diseases are triggered by external pathogenic factors. Although we cannot limit our exposure to environmental toxins, there are measures that can be taken to maintain gut health and avoid at least dietary triggers. Despite the variables, it seems clear from the research presented that dietary elimination of gluten, a toxin that can break through the intestinal Wei barrier, is integral to the health of autoimmune patients.

REFERENCES

[1] Nakazawa, Donna Jackson, The Autoimmune Epidemic (2009) p.229

[2] Maciocia, Giovanni, The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists (2005), p.53, quoting from The Spiritual Axis

[3] Jaminet, Paul and Shou-Ching, Perfect Health Diet: Regain Health and Lose Weight by Eating the Way You Were Meant to Eat (2013), p.201.

[4] Kresser, Chris, ‘Don’t Eat Toxins’. http://chriskresser.com/9-steps-to-perfect-health-1-dont-eat-toxins

[5] Jaminet, p.199.

[6] Carold Byrd-Bredmenner, Gaile Moe, Donna Beshgetoor, Jacqueline Berning, Wardlaw’s Perspectives in Nutrition, 8th Edition.

[7] Maciocia, p.194

[8] Chris Kresser in conversation with Alessio Fasano, August 8, 2012, http://chriskresser.com/pioneering-researcher-alessio-fasano-m-d-on-gluten-autoimmunity-leaky-gut

[9] Jaminet, p.198.

[10] It is also interesting to note that those who suffer from the autoimmune disease psoriasis often have increased serum levels of IgA antibodies to gliadin; http://www.ncbi.nlm.nih.gov/pubmed/8286249 similarly, in celiac patients, gliadin induces a sensitisation of T cells which is thought to play a role in the pathogenesis of psoriatic skin lesions. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319141/

[11] http://scdlifestyle.com/2012/03/the-gluten-free-lie-why-most-celiacs-are-slowly-dying/

[12] Referenced in Dr. Edward Tsang’s paper, ‘Compare and contrast the treatment of psoriasis as reported in the medical research literature, with the TCM approach.’ http://www.fengshuijinyan.com/E08_TCM_Articles/011%20psoriasis.pdf

[13] http://www.jaad.org/article/S0190-9622%2812%2900462-8/abstract

[14] Shen De-Hui, Wi Xiu-Fen, Nissi Wang, Manual of Dermatology in Chinese Medicine

[15] Li Lin, Treatment of Psoriasis with Traditional Chinese Medicine, translated by Liu Zhaohui, pp.28-9.

[16] http://thegoldensecrets.org/2014/10/14/5-big-mistakes-people-make-when-working-out/

[17] Lin, p.32

[18] David Kohn, ‘Joint Pain, From the Gut’. http://m.theatlantic.com/health/archive/2015/01/joint-pain-from-the-gut/383772/

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