Is There Really Such Thing As Leaky Gut?
Sometime during 2015 I was told I had “leaky gut.” I had no idea what it meant or if it was an actual diagnosis. I had not heard the term in college or any of my time working at Johns Hopkins Hospital. In December 2016, I was accepted and attended the 3-day preceptorship program at the University of Chicago Celiac Disease Center. During a presentation, one of the gastroenterologists talked specifically about “leaky gut” or what is called intestinal permeability. Now, more doctors are seeing leaky gut as an issue. Dr. Alessio Fasano, a gastroenterologist and a world-renowned expert on intestinal permeability is doing much research on this topic.
What is intestinal permeability (leaky gut)?
The intestine is lined with a layer of cells. There are small gaps in the intestinal wall (tight junctions) that allow small molecules (such as water, electrolytes and other nutrients) into the bloodstream to be used by the body. This layer also helps keep harmful substances out of our bloodstream. In someone with “leaky gut” these tight junctions are not working properly. When these gaps become loose, food may not properly break down before they slip through. The gut is now more permeable. This can also allow bacteria and toxins to enter the bloodstream. The body looks at these as invaders and starts an immune and inflammatory response.
When harmful substances get through the intestinal lining into the bloodstream symptoms can include bloating, digestive issues, fatigue, muscle aches and pains, confusion, and skin issues. These invaders tend to target different areas in the body, making symptoms vary from one individual to another.
Link with autoimmune disease
It is thought that leaky gut is a precursor to autoimmune disease. The immune system reacts when the proteins, bacteria, and viruses slip through the junctions. This in turn can trigger an immune response in those that are genetically susceptible. Multiple diseases can arise or be exacerbated due to leaky gut, including Crohn’s disease, celiac disease, Type 1 diabetes, multiple sclerosis, irritable bowel syndrome (IBS), asthma, cancer, food allergies and intolerances, and rheumatoid arthritis.
What contributes to intestinal permeability?
A variety of internal and external irritants can contribute to leaky gut, such as chemicals in processed foods, alcohol, pollutants, radiation & chemotherapy, NSAID use (such as indomethacin, ibuprofen and naproxen), trauma and burns, and viral or parasitic infections.
Testing for leaky gut
The only test used to monitor intestinal permeability is the lactulose-mannitol challenge. This is used mostly in research, but available in some commercial labs.
Dr. Fasano and his colleagues have focused much of their research on zonulin, which is a human protein. Zonulin tends to widen the intestinal cell junctions, which is thought to cause leaky gut. Based on research, people with an autoimmune disease tend to release more zonulin than the average population, making them more prone to leaky gut. Bad gut bacteria and gluten (via gliadin) are two of the most powerful triggers of zonulin release.
Can leaky gut be treated?
This is an area with a large variety of opinions, but some points that are agreed on are:
Other suggestions for helping to treat leaky gut:
Larazotide acetate is being studied to help those with celiac disease that follow a gluten-free diet, but continue to have symptoms. This drug is a tight junction regulator, which can help restore the open junctions (“leaky gut”). In celiac disease, exposure to gluten causes these junctions to open, thus leading to an inflammatory reaction. This medication is also being looked at for others that have intestinal permeability for a variety of other reasons. This medication is still currently being studied.
The information in this blog is not a substitute for professional medical advice, examination, diagnosis and treatment. Always seek the advice of your physician or other qualified healthcare provider before altering your diet, starting a new treatment or making changes to an existing treatment.
I asked the mother of one of my clients if she would like to write about her son's journey with IBS. Below is a very condensed version of his story. Some people are "fixed" quickly, while others, the pieces of the puzzle take a lot longer to fall into place. This client's mother was his biggest advocate and she deserves so much praise for getting her son where he is today.
Seeing my son in his first year of high school, enjoying the life of a typical teenager, I am grateful to Valerie Polley at Blue Tree Nutrition for helping him along his journey to better health.
For more than two years, digestive issues, headaches, dizziness and insomnia were making it impossible for my son to function normally. The problems began with a stomach virus, which ran a normal course with other family members, but persisted with my son. Because there were no physical signs the diagnosis became “school anxiety”. We felt that something else might be wrong, but experts were telling us otherwise.
Allergy testing came back negative. Counseling sessions didn’t seem to be helping. We homeschooled to avoid the pressure on all of us to get him to school no matter how he felt. We changed pediatricians when we realized that the first doctor wasn’t listening to our concerns.
After a while symptoms seemed to get better, so he returned to traditional school for junior high. Occasional symptoms occurred, but we told our son he had to tough it out and go to school as the medical professionals had told us to do. This worked until 8th grade when the GI issues and other symptoms began to occur daily. The new doctor had me keep a detailed record of symptoms and eating. He prescribed some medication which didn’t help.
The physician made a referral to a GI specialist. When we met the GI doctor in December 2016, she took time to get to know my son and to look at the records we had kept. She saw a pattern in the symptoms and told us that she thought that my son had IBS, a diagnosis that was confirmed with more testing.
It seemed that with a proper diagnosis and the right medication my son’s symptoms would go away, but that didn’t prove to be the case. We learned quickly that trial and error would be necessary, first to find a medication without troublesome side effects, and then to find the right diet. The third medication tried seemed to be the best, but symptoms were still occurring. The specialist had only provided us with clues about diet- “natural foods” and a note in a handout about something called, the Low FODMAP diet. The office scheduled an appointment for us with hospital dietician- in a month. I found the Low Fodmap App and began using it to find “safe” foods. We found that following the diet caused a decrease in symptoms, but my son was still having a lot of pain and not sleeping well at night.
I looked on the internet for dieticians specializing in the Low FODMAP diet and that is when I learned about Blue Tree Nutrition. Valerie was able to take more time with us and had a much better knowledge of how foods affect IBS than the doctors we had been working with. She gave me information on troublesome ingredients and ingredients hidden in food. She made many suggestions of appropriate products and recipes. After our meeting, she followed up with us several times to see how things were going and make suggestions for further changes. She is knowledgeable about the gastroenterologists in the area and helped us find a doctor that is more appropriate for my son.
Now taking the morning IBGard supplement suggested by the new doctor, medication at night, and avoiding the FODMAPs that cause reactions, my son is a healthy and happy 14 year old.
I attended a three day GI conference at the University of Michigan in September. It was an amazing conference packed full of presentations from some of the best GI doctors and dietitians. One presentation was on a topic I had never heard of, so I was intrigued and ready to learn more about it.
Congenital Sucrase-Isomaltase Deficiency (CSID) is a rare disorder that causes individuals the inability to digest certain sugars due to an absence or low levels of two digestive enzymes, sucrase and isomaltase. Both of these enzymes are involved in the digestion of sugar and starch. Table sugar is broken down into glucose and fructose with the help of the sucrase enzyme. Isomaltase is one of the several enzymes that help digest starches.
Both sucrose (found in fruits, and known as table sugar) and maltose (sugar found in grains) are disaccharides, which means they are made of two simple sugars. During digestion, intestinal enzymes break these down into simple sugars called monosaccharides. Sucrose=glucose + fructose and maltose=glucose + glucose. An individual with CSID has difficulty breaking down the disaccharides into monosaccharides that the body uses for fuel. These disaccharides are too large to be absorbed in the intestines by the microvilli (known as the brush border).
Starch can be a simple or complex carbohydrate. Simple carbohydrates have one or two sugar molecules, and complex carbohydrates have three or more sugars linked together.
Multiple enzymes are needed to properly digest starch. Digestion begins in the mouth with an enzyme in the saliva called amylase. Digestion continues in the stomach by further breaking down the food. In the small intestine, starch is processed by an enzyme called pancreatic amylase and converted into maltose and sucrose. The brush border contains numerous enzymes (sucrase, lactase, maltase) to continue the breakdown of digested food into smaller particles that can be better absorbed. The isomaltase enzyme breaks the bonds linking sugars into glucose, which can't be broken down by amylase or maltase. This is one of the final steps in the digestion of starch to glucose.
To sum it up, those with CSID lack the sucrase and isomaltase enzymes to properly break down the food to a simpler form, so the body can absorb it.
Without the proper enzymes, digestion can't take place correctly and individuals can have symptoms, such as:
So, what do you do if you suspect you have CSID?
Visit sucroseintolerance.com to take their quiz. On that site there is also an "ask your doctor" form to take to your physician. A sucrose breath test can help with the diagnosis. This can be ordered by your doctor or I can order a complimentary sucrose breath test to be sent to your home.
What if you have a positive breath test?
You will do a two-week elimination diet of sucrose and starch, followed by a gradual reintroduction of both. The reintroduction will help identify how much of these foods you can tolerate. Many like the guidance of a dietitian familiar with this deficiency to help them navigate through the elimination and reintroduction phases. Others also do the diet along with a test of the sucrase enzyme, Sucraid® (sacrosidase) Oral Solution. The sucrase enzyme can be purchased through One Patient Services, a subsidiary of QOL, Medical, LLC, the manufacturer of Sucraid® Oral Solution, at SucraidASSIST.com.
Please consult with your doctor regarding your symptoms and for a final diagnosis.
If you have any questions regarding Congenital Sucrase-Isomaltase Deficiency, please feel free to call or text me at 410-963-4782 or email at email@example.com.
I promise I won't just post muffin recipes. They are just one of my favorite quick foods for breakfast or a snack.
-1/2 cup sugar
-1/2 cup oil (your choice what type)
-2 cups spinach
-1 1/4 cup almond flour**
-1 cup gluten-free oats***
-1/2 tsp salt
-1 tsp baking soda
-1/4 cup chia seeds**
-1/4 cup ground flax seed**
-1/4 to 1/2 cup chocolate chips (dark or milk chocolate)**
-In a blender mix sugar, bananas, eggs, oil, and spinach.
-In a separate bowl, mix together almond flour, gluten-free oats, salt and baking soda.
-Remove banana mixture from blender and stir with dry mixture.
-Stir in chia seeds, flax seeds and chocolate.
Spray and fill muffin trays 1/2 full with batter. Bake at 350 degrees for 20 minutes. Makes 12-15 muffins.
*Those following a low FODMAP eating plan often times tolerate the less ripe banana over a very ripe banana. Either one can be used in this recipe, depending on your toleration.
**Based on the Monash App the green light is given for:
-Almond flour at (1/4 cup)
-Gluten-free rolled oats (1/2 cup)
-Ground flax seeds (1 TBSP)
-Chia seeds (2 TSBP)
-Milk chocolate (1 fun size bar)
-Dark chocolate (5 squares)
Since this makes over a dozen muffins, these green light servings are safe. Just remember not to eat too many muffins each day!!! These can be refrigerated or frozen.
***Caution using oats for the first 6 months if you are a newly diagnosed celiac. If you are past the 6 months or have a gluten sensitivity please purchase certified gluten-free oats.
Many of my clients comment that co-workers, friends and even sometimes family are not understanding of their diagnosis or why they are eating a certain way. It is difficult to be in social settings with food and feel like you aren't eating like everyone else, or able to eat anything at all. I reached out to a licensed mental health counselor, Denise Cutshaw to get her opinion on how individuals can deal with outside pressure when given a diagnosis that effects the foods they can eat. Enjoy! And at the end of her blog are a few extra questions I had for her.
Whether you, or a loved one such as your spouse, child or other family member has been recently diagnosed with any type of gastrointestinal issue, food allergy or intolerance, it can feel very overwhelming. You start with educating yourself on the types of foods that are “safe” and may even reach out to a registered dietitian to help you with a food plan (highly recommended!).
Then…the feelings set in as you begin to navigate through get togethers, parties, celebrations, holidays, office breakfasts/lunches, and traveling. Common feelings that may arise are loneliness, isolation, feeling misunderstood, frustration, anger, defeat, anxiety or even depression. If these feelings are persistent for you, it may be beneficial to talk with a counselor. Counseling can help someone with a recent food allergy/intolerance or autoimmune diagnosis, such as celiac, better cope with these feelings and how to ask for help and support from loved ones and friends. Children can especially find benefit in talking with a counselor and seeking out support groups to help normalize their feelings by being exposed to others with similar circumstances.
Counseling can help an individual process and work through some of these feelings through different modalities of treatment. Cognitive Behavioral Therapy is extremely beneficial in identifying one’s thoughts, feelings, and behaviors as it relates to food and outings with food. Assertiveness skills can be taught and reviewed as a means of making sure you build a safety net around your core people that are aware of restrictions and are sensitive to your needs or the needs of your child. Thirdly, psychoeducation can be provided through the counseling relationship as well as with your dietitian on acquiring knowledge and education on your limitations/diagnosis.
Life transitions and events can certainly contribute to an onset of depression and/or anxiety. When to be concerned or seek out help for depression and/or anxiety symptoms depend on a multitude of factors. Consider these presenting factors for depression and seek counseling to help address these:
Questions for Denise:
Question: How should patients/clients deal with co-workers, friends, etc. that continue to make comments about what they are or aren't eating? Even adults can somewhat "bully" another adult and make them uncomfortable in social situations with food. Often times these individuals avoid situations that involve food because it is uncomfortable, especially around those that don't understand. This comes up with a handful of clients and it is easy for me to tell them to tell their co-workers it is a doctor's order, but this doesn't always make the situation better.
Answer: It's hard to deal with people that don't understand and make comments about food whether they are rude comments or bringing attention to it. Some ways to manage that is to be as educated as you can be on what foods are "ok" for you and why so you can respond with "I've learned so much about what works for me" or "it was a little difficult for me too at first to understand, but I've really educated myself and found what works and it is helping tremendously".
When loved ones that we are very close to continue to make comments, using "I feel" language is also helpful. For example. "When you make comments about my food, it makes me feel anxious and on edge. I need for you to be understanding of my food choices and not make those comments". That type of language allows an openness about how the comments make you feel and if the person is still unable to honor your needs, you can then decide to restrict your time with them, especially around food. You can also invite close loved ones with you to a dietitian or doctor appt. to assist in education on the matter so they have a better understanding.
Question: Do you encourage a significant other (if the person with the diagnosis is an adult) to join them for these professional visits, such as with the dietitian or yourself? Some family members are not supportive, so do you think it helps to have them present or hurt? I see this with individuals that have been dealing with these GI issues for a long time.
Answer: As a counselor, I truly feel that getting as many people involved in your care is so very important. It can assist in the person's support network with education but also insight into the feelings of the person affected and how these food issues impact them on a daily basis. For children, any caregiver that will be caring for the child and feeding them meals or snacks would benefit from attending any appointments as well. Even the parents of friends of your child can be educated and provided a "safe list" of snacks and foods okay to eat while your child is over at their home playing. This helps reduce any potential anxiety for the parent or child and the child doesn't feel "singled out" having to sit out for snacks during play times.
Overall, being assertive and open is always best in the care for yourself or your loved ones who struggle with food issues. If you're finding you're avoiding situations around food either yourself or your child, it could be an indication you may need to be more open and assertive about your needs or the need of your child as well as your feelings so people can better understand and be educated.
Denise Cumshaw, LMHC is on leave at this time and not accepting new patients, but if you need more information or feel like you may benefit from counseling services please contact her at firstname.lastname@example.org.
I am always looking for something different to eat for breakfast. I'm not one of those that can eat the same thing every day, so I look for variety in my meals and snacks. Plus, I often need something that I can just grab and bring with me.
-2 cups grated zucchini
-1 cup blueberries or raspberries (after measuring 1 cup, mash or puree them up-will be about 1/2 cup)
-1 cup spinach (after measuring 1 cup, chop up the spinach)
-1/2 cup chia seeds
-1/4 cup sugar (you could add less if you would like-my berries were a bit sour tasting)
-1/2 cup oil
-1/2 cup liquid, such as regular milk (if tolerated), lactose free milk, almond milk, etc.)
-1 cup gluten-free oats
-1 cup flour (I used Bob's Red Mill GF, but you could use anything, such as almond flour, etc)
-1 tsp salt
-1 tsp baking soda
-1/4 tsp baking powder
-1/4 cup ground flaxseed (FODMAP approved to 1 TBSP-these make 15-18 muffins, add less if needed)
-Fold in whole berries, nuts, chocolate chips, etc.
Mix the first 8 ingredients. In a separate bowl, mix the remaining ingredients (except the extras, such as nuts, chocolate chips, etc). Then, mix together the two bowls of ingredients. Fold in extras if you are adding them. Spray a regular size muffin tin and fill to the top with muffin batter. Bake at 350 degrees for 20 minutes.
This is a FODMAP friendly muffin. It is gluten-free as well, but if you are newly diagnosed even gluten-free oats are cautioned against for the first 6 months. Please leave your comments if you decide to make them! Let me know if you change anything. I am always open to suggestions!
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