Amy Burkhart, MD, RD

Amy Burkhart, MD, RD

Amy Burkhart, MD, RD, is a board-certified emergency medicine physician and registered dietitian. She also trained in integrative medicine with Dr. Andrew Weil at the University of Arizona Center for Integrative Medicine. Her practice is located in Napa, CA.
1100 Lincoln Ave. Suite 200
Napa, CA 94558
(707) 927-5622 Office
The gluten-free diet may not be all that is needed to treat celiac disease.

bacteria in usI was diagnosed with celiac disease twelve years ago. It was quite a journey to arrive at the diagnosis, as it is for so many.When I finally found the answer, the sense of relief was overwhelming. I was additionally comforted by the fact that my treatment was a diet and not medication. Like most celiac patients, I was told to start a gluten-free diet and all would be well. Unfortunately, it wasn’t that easy. The diet was manageable, and my symptoms improved dramatically, but many persisted.

It is a common misconception that all celiac patients get completely well with only the gluten-free diet as a treatment. Many do, but many do not. A2003 study found that celiac patients on a gluten-free diet have twice as many gastrointestinal symptoms as the general population. For many patients, continued gluten ingestion is the cause of their persistent symptoms. When patients strictly adhere to the gluten-free diet and symptoms persist, however, the answer may lie within.

A new Finnish study published in the American Journal of Gastroenterology evaluated celiac patients suffering from persistent symptoms while adhering to a strict gluten-free diet. The subjects had been on a gluten-free diet for at least three years. Their lab results and biopsies had normalized, but they still had symptoms. What the researchers found is of potentially great significance to the future of celiac disease treatment. While the paper did not receive the attention in popular media that many gluten-related articles receive these days, the findings of the study are vitally important to anyone with celiac disease.

The microbiome defined

Before I explain further, it is important to talk about the microbiome. The term refers to the trillions of bacteria that inhabit our bodies in our gastrointestinal tract, our skin, hair, etc. These bacteria are vital to our existence. We need them. They also significantly impact our health. The genetic material they contain may be as important as the DNA we inherit from our parents and may be influencing our predisposition to certain diseases.

Just as we have our own genetic make-up, we also have a unique microbiome. The health  of our microbiome appears to play a pivotal role in our overall health. The study of the microbiome is so important that the National Institutes of Health initiated the Human Microbiome Project in 2007  to determine its overall impact on health and disease.

The amount of research on this topic is expanding rapidly, and alterations in the microbiome have been correlated to conditions such as obesityinflammatory bowel disease, otherautoimmune diseases, and cancer. The information resulting from microbiome research is changing the practice of medicine.

Celiac disease and the microbiome

Several studies have reported imbalances in the microbiome in people with celiac disease, and another showed the bacteria we have may affect what symptoms we display. This may explain why some celiac patients experience headaches, while others have joint pain; the type of bacteria they have in their intestine may be playing a role.

Results of the new Finnish study 

The Finnish study published last month found less bacterial diversity (fewer different types of bacteria) and an imbalance in certain types of bacteria in celiac patients with persistent symptoms.  The bacterial make-up of people with ongoing symptoms resembled that of untreated celiac patients. Why this occurs in some people is not known, but may be related to a delay in diagnosis and a “resetting” of what is a normal microbiome. The microbiome stays relatively stable in healthy people, but when illness or antibiotics upset the balance, the microbiome is altered. In theory, the longer this occurs, the higher the risk of a new microbiome “set point.”

How this new information may affect the treatment of people with celiac disease

This is exciting news for people with celiac disease. If we can learn to optimize and balance the microbiome in addition to following a gluten-free diet , persistent symptoms may be alleviated. If we can modulate the microbiome with targeted probiotics or even fecal transplants, the potential for optimal health is improved.

Since a correlation is also being found between bacterial imbalance and autoimmune diseases, balancing and optimizing the microbiome may also decrease the risk of other autoimmune diseases, such as thyroid disease, that occur more commonly in people with celiac disease. And perhaps by modulating the microbiome, we can even decrease the risk of cancer. The possibilities are exciting.

Optimizing your microbiome

Effective treatments to modulate the microbiome are in development, but until then there are things we can do to optimize it on our own.

  1. Diet:  A plant-based diet, free of processed foods and low in meat has been shown to improve microbiome diversity. Including cultured or fermented foods may also improve intestinal health by providing natural forms of probiotics
  2. Exercise:  Exercise has been shown to positively correlate with improvement in the diversity of our microbiome. Set a goal of 30-45 minutes daily.
  3. Sleep:  Improved sleep may improve the microbiome composition. Conversely, an altered microbiome can worsen sleep.
  4. Stress management:  An altered microbiome has been shown to contribute to anxiety and depression, and higher stress levels correlate with an alteration in the microbiome. Improve your microbiome by using your favorite stress reduction technique on a daily basis.
  5. Weight management: Maintaining a healthy weight will help promote a healthy microbiome.
  6. Probiotics and prebiotics: These can be used to manipulate the composition of the microbiome and targeted or specific formulations for specific disease states may be an important part of the future of medicine.

Popular articles on the microbiome:

You Are Your Bacteria: How the Gut Microbiome Influences Health” by  Veronique Greenwood, Time Magazine, Aug. 29, 2013

Some of My Best Friends Are Germs“ By Michael Pollan, The New York Times Magazine, May 15, 2013