Ask the Doctor: February/March 2018

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Q&A with celiac expert Alessio Fasano, MD.

Last November, Dr. Alessio Fasano, director of the Center for Celiac Research and Treatment and director of the Mucosal Immunology and Biology Research Center at Massachusetts General Hospital, gave the keynote address at the Institute for Integrative Health’s In Good Health Wellness Expo in Baltimore. Associate editor Jules Shepard was there. In her interview with Dr. Fasano, he expands upon his presentation and discusses factors related to the development of celiac disease and other autoimmune conditions.

GF&M: You assert that food can either cause or ameliorate disease. What has led to this conclusion and what can we do to avoid disease or to heal with food?

Dr. Alessio Fasano

Jules Shepard

Dr. Fasano: There are really two categories of food—anti-inflammatory food and inflammatory food. We know this because we see how food can make certain conditions better or worse. We’ve been witnessing the incidence in allergies, Inflammatory Bowel Disease, autism, cancers, autoimmune disease and certain neurodegenerative diseases over recent generations and there has been an incredible increase. Because we know that the mutation of human genes which could potentially explain these epidemics only takes place over hundreds of years, we know that this increase in disease must come from changes in the environment, rather than genetic mutations.

Take autism as an example. In the 1970s, autism rates were 1 in 5,000; they are now 1 in 66. It’s a staggering thought that 1 in 4 boys in the next generation will have autism. This is a true epidemic. Why is this happening? We think it may be tied to inflammation in some way.

GF&M: What are the leading theories in support of the thought that the environment—or our food—is causing more disease in modern generations?

Dr. Fasano: Once upon a time, we had something called the backyard where we used to go and play and get dirty. This backyard trained our immune systems to be strong and to fight the right invaders. Our kids don’t play in the backyard anymore. They spend most of their time on a couch. We don’t play in the dirt; we play on the computer, the phone or the TV. Our kids are too clean and that makes them vulnerable to inflammation because their immune system has not been properly trained to fight invaders.

While this ‘hygiene hypothesis’ could explain a lot of things, I think that it helps to explain one reason why we have more disease now.

GF&M: When did we start to see an increase in inflammatory disease?

Dr. Fasano: Until the late 1800s when antibiotics were not discovered yet, humans used to die of infection or injury. Forty-three was the average lifespan. That age has doubled in the last century.

So while infections and sudden deaths have decreased, inflammatory diseases have increased. Multiple sclerosis, Crohn’s, type 1 diabetes, asthma—these are all trending up. We are now dying slow deaths from chronic inflammatory diseases instead.

GF&M: Are we born with the genetic predisposition to disease?

Dr. Fasano: No. We are not born with a destiny to develop chronic inflammatory diseases. Whether we develop these diseases is a result of our lifestyle. We know this because we use celiac disease as a model for understanding other inflammatory conditions.

No tissue or organ in the body is spared by celiac disease’s inflammatory process. No age, sex or race is spared either. And while we don’t yet know the trigger for any other autoimmune disease, we know for celiac that the trigger is gluten. However, there are many human genes involved in the pathogenesis of celiac disease. In fact, there are over 60 genes linked to celiac disease and there are probably thousands linked to the functions of those genes which regulate gut permeability, inflammation and other contributing conditions.

We know that genes and gluten are necessary but not sufficient to develop celiac disease, for if they were, why would only 25 percent of identical twins contract the disease? Why would some develop celiac at age two and others at age 82? How could you explain the broad range of symptoms? And how else could you explain that the same person whose blood work shows no celiac later develops the disease?

So we believe that genes plus several environmental conditions (including food) cause celiac to manifest. This theory is further supported because the prevalence of celiac disease doubles every 15 years—far too quickly for gene mutation to be the cause.

GF&M: Why is this happening?

Dr. Fasano: Many people believe it’s due to genetically engineered increases in the gluten content of wheat. However, we know that the gluten content in wheat has been increasing since the time of the Romans. Thanks to farmers’ cultivation techniques, gluten content rose from 4 to 8 percent during the Renaissance to 12 percent during the Agricultural Revolution; yet there was no corresponding increase in the percentage of the population with celiac disease until now. In fact, we are eating less gluten now than we were in the 1800s, yet we have more celiac.

So we do not think you are born to have a disease but we don’t yet know what environmental triggers cause the disease to be expressed. With celiac, we believe you must have the genes and some environmental trigger that causes intestinal leaks, immune system malfunctions and a microbiome out of balance.

Dr. Alessio Fasano and Jules Shepard

GF&M: How does the microbiome come into play in the development of disease?

Dr. Fasano: We are all made up of bacteria, which we affectionately refer to as our unique microbiome. For each cell in our body, there are ten bacteria. For each gene, there are 150 which are expressed by our microbiome. Not all these bacteria are bad. In fact, many are good and are necessary for good health. But when we are too clean or when we otherwise alter the natural microbiome, we may end up with the development of disease and even conditions like depression and obesity.

We conducted a study over 10 years, following 700 infants with the genetic predisposition for celiac. We expected factors like breastfeeding or the delayed introduction of gluten in their diet to protect these children from developing the disease—but they did not. In fact, the only factor that seemed to have any effect on whether a child developed the disease was whether there were any gastrointestinal infections in the first year of life.

Natural childbirth (rather than cesarean section), as well as breastfeeding, contribute most prominently to the health of the microbiome in the crucial first 1,000 days of life. However, a junk food diet, multiple infections, multiple antibiotics—all these things also alter the microbiome and instigate inflammation which, with the wrong set of genes, leads to disease.

We’ve found that the biggest factor in triggering this inflammation is actually our diets—and that is the thing that has changed the most over time. The ancient Mediterranean Diet of our ancestors is instructive: meat eaten only rarely (extremely lean meat, at that); fish eaten occasionally; a high intake of olive oil; and a basic diet of fruits and vegetables. This diet was part of a lifestyle of eating as a family, outdoor play, dancing and physical activity, and growing old in a community and in a close family, all of which led to healthy life. Look how far we’ve departed from that food and lifestyle pyramid and look at the rate of inflammatory disease we have today. We believe this connection is not to be ignored.

GF&M: What can we do for ourselves to prevent or perhaps even reverse some inflammatory disease?

Dr. Fasano: With celiac, you take away the gluten and the body heals itself in most cases. We don’t yet know the triggers for other inflammatory diseases but we do know that contracting those diseases is not destiny, even if you carry the genes for it. Whether we do or do not develop disease is based on our lifestyle and its effects on our microbiome. We have the ability to change our health destiny with food and activity—and without a pill. That’s encouraging.

Associate editor Jules Shepard is author of Free For All Cooking (DaCapo Perseus), The First Year: Celiac Disease and Living Gluten-Free (DaCapo Perseus) and, Nearly Normal Cooking for Gluten-Free Eating (CreateSpace).

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