Grain Brain - Chapter 2 (second post about the book)

On Sunday, December 8^th, I wrote my first blog post about Grain Brain, by David Perlmutter, MD.  It covered the introduction and 1^st chapter of the book.  This post covers chapter two of the book titled:  The Sticky Protein – Gluten’s role in Brain Inflammation.

As a reminder, I have decided to blog about this book for two reasons:  1) to make the information stick in my own brain; 2) to hear your comments.  Please leave comments and let me know your thoughts.  I welcome a lively discussion on the thoughts presented in my blog posts.  If you decide to read the book, I’d be very interested to know what you think of it.

Chapter 2 of Grain Brain is focused on the discussion of gluten and the role it plays in celiac disease and a variety of brain disorders.  The chapter starts with stories about three of Parlmutter’s patients; one suffered from persistent migraines, one suffered from bipolar disorder, and one suffered from involuntary movement and learning disorders.  After listening to all three of these patients’ complaints, Perlmutter tested each of them for gluten sensitivity, all with positive results.  All three of the patients went on gluten free diets and all three improved dramatically as a result.  Perlmutter states that these cases reflect a pattern that he has witnessed in many of his patients.  Patients come into his office complaining of vastly different symptoms and ailments that are often alleviated by removing gluten from the diet.  He states, “It is my belief that gluten is a modern poison, and that the research is compelling doctors like me to notice and re-examine the bigger picture when it comes to brain disorders and disease.”

Perlmutter describes gluten as a protein composite that acts as the ‘glue’ that holds flour together to make bread products.  Gluten can be found in many grains such as wheat (most common source in the USA), rye, barley, spelt, kamut, and bulger.  In addition, gluten can be found in many other common household items; from cheese spreads to mascara to hair conditioners.

While many people are aware of celiac disease they may not know that there is a big difference between gluten sensitivity and celiac disease; the latter is an extreme manifestation of the former.  Celiac disease is basically a severe allergic reaction to gluten that causes damage specifically to the small intestine.  While celiac disease is the most recognized and most severe form of gluten sensitivity, gluten sensitivity can impact any organ in the body.  Perlmutter explains that food sensitivities (not just gluten sensitivity) are usually a response from the immune system.  They also occur when the body doesn’t have the right enzymes to break down a certain food.  He states that, “In the case of gluten, its ‘sticky’ attribute interferes with the breakdown and absorption of nutrients.  Poorly digested food leads to a pasty residue in your gut, which alerts the immune system to leap into action, eventually resulting in an assault on the lining of the small intestine.”  But Perlmutter stresses, over and over again, that even if you don’t experience typical digestive issues related to gluten sensitivity, gluten sensitivity could lead to attacks elsewhere in your body, such as the nervous system.  When we negatively react to food, our body “attempts to control the damage by sending out inflammatory chemicals, killer cells among them, to wipe out the enemies.”

Occasionally, the books technical language caused me to have a little trouble absorbing the message.  When I read the next several paragraphs I got hung up because I did not know the exact definition of some words, so I looked them up and am providing you with the definitions here:

antigen
noun
1.  Immunology.  Any substance that can stimulate the production of antibodies and combine specifically with them.
2.  Pharmacology.  Any commercial substance that, when injected of absorbed into animal tissues, stimulates the production of antibodies.

cytokine Any of several regulatory proteins, such as the interleukins and lymphokines, that are released by cells of the immune system and act as intercellular mediators in the generation of an immune response. Also called  chemokine .  gliadin noun Biochemistry . 1. a prolamin derived from the gluten of grain, as wheat or rye, used chiefly as a nutrient in high-protein diets. 2. any prolamin. prolamin noun Biochemistry . any of the class of simple proteins, as gliadin, hordein, or zein, found in grains, soluble in dilute acids, alkalis, and alcohols, and insoluble in water, neutral salt solutions, and absolute alcohol.

Perlmutter wants the reader to understand how a sensitivity to gluten can impact the brain, so he explains the following:

Prolamins are a class of simple proteins which are soluble in dilute acids, alkalis, and alcohols but are not soluble in water and neutral salt solutions.  Gliadin is a prolamin specific to gluten.  Gluten sensitivity is caused by an elevated immune system response to gliadin.  Inflammation, which is the cornerstone of many brain disorders, can be initiated by this immune system response.  As the inflammation cycle evolves, cytokine chemicals, which are antagonistic towards the brain, are released and collected and can attack the brain.  This process can damage brain tissue and leave the brain vulnerable to dysfunction and disease, particularly if the damaging conditions persist over a period of time.  Elevated cytokines are seen in Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, and autism.  99% of the people whose immune systems react negatively to gluten don’t know it.

Perlmutter likes a conclusion that Professor Marios Hadjivassiliou (one of the most well-respected researchers in the area of gluten sensitivity and the brain at the Royal Hallamshire Hospital in Sheffield) draws in a 1996 article published in Lancet, “Our data suggest that gluten sensitivity is common in patients with neurological disease of unknown cause and may have etiological significance.”  (Definition:  Etiological:  Of or pertaining to causes or origins).

Perlmutter writes the following: “Dr. Hadjivassiliou goes on to state that ‘gluten sensitivity can be primarily, and at times, exclusively, a neurological disease.’  In other words, people with gluten sensitivity can have issues with brain function without having any gastrointestinal problems whatsoever.”  For this reason, Perlmutter tests all of his patients who have unexplained neurological disorders for gluten sensitivity.  Perlmutter states, “I love how Dr. Hadjivassiliou and his colleagues stated the facts in a 2002 editorial in the Journal of Neurology, Neurosurgery, and Psychiatry titled ‘Gluten Sensitivity as a Neurological Illness’:

‘It has taken nearly 2,000 years to appreciate that a common dietary protein introduced to the human diet relatively late in evolutionary terms (some 10,000 years ago), can produce human disease not only of the gut but also the skin and the nervous system.  The protean neurological manifestations of gluten sensitivity can occur without gut involvement and neurologists must therefore become familiar with the common neurological presentations and means of diagnosis of this disease.’”  (Definition:  Protean:  readily assuming different forms or characters; extremely variable.)  

The editorial went on to state, ‘Gluten sensitivity is best defined as a state of heightened immunological responsiveness in genetically susceptible people.  This definition does not imply bowel involvement.  That gluten sensitivity is regarded as principally a disease of the small bowel is a historical misconception.’

After Perlmutter concludes this rather scientific discussion of gluten sensitivity, he summarizes the history of the discussion of celiac disease and when gluten was finally linked to celiac and finally, to brain dysfunction.  The term celiac was first introduced in the 1^st century AD by Aretaeus of Cappadocia, a distinguished ancient Greek doctor.  There is evidence of the discussion of celiac disease throughout medical literature since then, with Dutch pediatrician Dr. Willem Karel Dicke finally linking celiac to gluten as a result of the Dutch famine of 1944.  During the famine bread and flour were scarce.  Dr. Dicke noticed that celiac disease all but disappeared in children, when it had been a fairly common problem before the famine.  Dr. Dicke reports that after the famine, celiac rates rose again, with mortality rates returning to original rates.  About a century ago, the first anecdotal reports began to emerge, in which doctors documented neurological disease in patients with celiac.  At that time, they attributed the neurological problems to a nutrient deficiency caused by the inability to digest food properly, not the brain’s reaction to a gluten sensitivity.  The turn-around, connecting gluten sensitivity directly to neurological disease, is very recent.  In 2006, the Mayo Clinic came out with a report in the Archives of Neurology with a conclusion that was a “game-changer” according to Perlmutter.  It reads, “A possible association exists between progressive cognitive impairment and celiac disease, given the temporal relationship and the relatively high frequency of ataxia and peripheral neuropathy, more commonly associated with celiac disease.”  (Ataxia:  the inability to control voluntary muscle movements and maintain balance, most frequently resulting from disorders of the brain.  Peripheral neuropathy:  nerve damage that encompasses a wide range of disorders in which the damaged nerves outside of the brain and spinal cord cause numbness, weakness and pain.)

The study that led to the above stated conclusion included 13 patients who showed progressive cognitive decline within two years of the onset of celiac disease (anyone whose cognitive decline could be pinned on a possible alternate cause was excluded from the study).  Two things of significance were noted among these patients, cognitive decline could not be attributed to nutritional deficiencies and the patients were relatively young to have dementia (median age 64; age range was 45 – 79).

Dr. Joseph Murray, a gastroenterologist and the study investigator wrote; “There has been a fair amount written before about celiac disease and neurological issues like peripheral neuropathy…or balance problems, but this degree of brain problem – the cognitive decline we’ve found here – has not been recognized before.  I was not expecting there would be so many celiac disease patients with cognitive decline.”  He reflected that it was unlikely that these patients’ conditions reflected a “chance connection.”  One of the findings of the study was that patients who were put on a gluten-free diet experienced “significant improvement” in their cognitive decline.  In this report, Dr. Murray mentioned the possible link between brain impairment and inflammatory cytokines.

When participants in the study stopped consumption of gluten, their brain scans revealed noticeable changes in the white matter on the brain that could easily be confused with multiple sclerosis or small strokes.   

Dr. Perlmutter notes, “This is the reason I always check for gluten sensitivity in patients referred to me with a diagnosis of multiple sclerosis; on many occasions I’ve found patients whose brain changes were in fact not related to multiple sclerosis at all and were likely due to gluten sensitivity.  And lucky for them, a gluten-free diet reversed their condition.”

Towards the end of Chapter 2, Perlmutter sites yet another article, this one written by Dr. Rodney Ford of the Children’s Gastroenterology and Allergy Clinic in New Zealand, published in 2009 titled, “The Gluten Syndrome:  A Neurological Disease:” The article states: “The fundamental problem with gluten is its’ interference with the body’s neural networks…gluten is linked to neurological harm in patients, both with and without evidence of celiac disease.”  Ford added, “Evidence points to the nervous system as the primary site of gluten damage,”  he concluded that, “the implication of gluten causing neurological network damage is immense.  With estimates that at least one in ten people are affected by gluten, the health impact is enormous.  Understanding the gluten syndrome is important for the health of the global community.”

Perlmutter starts summarizing the chapter by telling us that he has inundated us with all of this data because even though we may not be as sensitive to gluten as an individual with celiac, the data shows we may all be sensitive to gluten from a neurological stand-point.  In this chapter, Perlmutter wants us to get a scope of the problem, as he sees it, and wants us to have a firm understanding that gluten can be the root cause behind inflammation in our system that can have a damaging impact on more than just our gut.  He is absolutely convinced that this inflammation damages our brain, too, and he does his best in chapter 2 to introduce us to enough data that we begin to consider the possibility that he may be right.