WEBVTT - Ep 146 Celiac Disease: Rootin tootin gluten

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<v Speaker 1>Hi everyone.

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<v Speaker 2>My name is Becca, and today I'll be sharing my

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<v Speaker 2>experience with Celiac disease. I do want to note here

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<v Speaker 2>that a good portion of this story is actually going

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<v Speaker 2>to be about the impact of Celiac on my mental health,

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<v Speaker 2>which is an aspect of the disease that isn't talked

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<v Speaker 2>about as much as the quote unquote physical symptoms are.

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<v Speaker 2>When I was in sixth grade, so about eleven years old,

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<v Speaker 2>I started to get really bad stomach aches. I missed

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<v Speaker 2>a good bit of school because of this, which prompted

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<v Speaker 2>my parents to take me to see my pediatrician. My

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<v Speaker 2>pediatrician recommended that I go get blood work done. I

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<v Speaker 2>was terrified of needles at this age and obviously did

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<v Speaker 2>not want to hear this, but I do remember my

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<v Speaker 2>pediatrician saying and passing that it could be Celiac disease,

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<v Speaker 2>but that she was pretty sure it wouldn't be. After

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<v Speaker 2>a very traumatic blood test for everyone involved, my pediatrician

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<v Speaker 2>called my home a few weeks later to let me

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<v Speaker 2>know that my blood work had tested positive for celiac.

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<v Speaker 2>I then had to get a biopsy of my small

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<v Speaker 2>intestine to confirm this. The biggest thing that I remember

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<v Speaker 2>from this period was being absolutely terrified of the biopsy.

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<v Speaker 2>I don't even think it had even processed yet that

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<v Speaker 2>I could have an autoimmune disease triggered by my favorite foods.

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<v Speaker 2>I was a kid, so the idea of going to

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<v Speaker 2>the hospital and getting an IV dominated my understanding of

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<v Speaker 2>the situation, and the biopsy was really hard. I drink

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<v Speaker 2>an obscene amount of water beforehand to make the veins

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<v Speaker 2>in my arms easier to access, but it didn't work

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<v Speaker 2>and the nurse had to use the veins on my

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<v Speaker 2>hand to get in the IV. I even had to

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<v Speaker 2>be wheeled out of the hospital because it took a

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<v Speaker 2>while for the anesthetic to wear off. But after all

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<v Speaker 2>of that, the results came back positive and confirmed officially

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<v Speaker 2>that I had Celiac disease. Celiac is an autoimmune disease

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<v Speaker 2>that prevents the body from properly digesting gluten, which is

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<v Speaker 2>a protein that is found in wheat. The only treatment

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<v Speaker 2>is to stop eating glutin, which is exactly what I did.

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<v Speaker 2>The good thing is that within a month or so

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<v Speaker 2>of going gluten free, I did start to feel better.

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<v Speaker 2>I hated the new food that I had to eat

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<v Speaker 2>because it was bland, but I could at least recognize

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<v Speaker 2>that my body wasn't in nearly as much pain as

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<v Speaker 2>it used to be. I had more energy. The awful

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<v Speaker 2>cramps that made me feel like my stomach was eating

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<v Speaker 2>itself grew more infrequent. There was, however, a significant mental

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<v Speaker 2>impact of Celiac disease that I want to highlight. I

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<v Speaker 2>was diagnosed with Celiac right when I was hitting puberty

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<v Speaker 2>as a girl in the early twenty tens, and even

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<v Speaker 2>though I was only eleven, I was already acutely aware

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<v Speaker 2>of the seeming requirement for people like me to be

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<v Speaker 2>small and thin. I was already self conscious of my body,

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<v Speaker 2>and I want to note that Celiac did not cause

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<v Speaker 2>all the issues I would develop with food and body confidence. However,

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<v Speaker 2>it definitely exacerbated them. Suddenly, food, which I'd already had

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<v Speaker 2>a tense relationship with, became really bad, and not just

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<v Speaker 2>bad but harmful. Because of Celiac disease, food actually hurt me.

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<v Speaker 2>It felt like I had been failed not just by food,

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<v Speaker 2>but also by my body. I received all of my

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<v Speaker 2>early treatment and tests at a children's hospital, and this

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<v Speaker 2>included a specialized meeting with the dietisation who explained celiac

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<v Speaker 2>to my parents and me, including what foods to avoid,

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<v Speaker 2>possible meal plans, and how to identify gluten in seemingly

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<v Speaker 2>unsuspecting food products. Gluten can go by many terms maltodextrin, rye,

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<v Speaker 2>malt name a few, so I had to get really

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<v Speaker 2>good at reading the ingredients lists on foods. Unfortunately, the

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<v Speaker 2>calories were always right by the ingredients. Food became a

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<v Speaker 2>point of stress. Eating was no longer fun, but rather

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<v Speaker 2>a minefield that I had to navigate for every meal

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<v Speaker 2>and every snack. I still can't really express how much

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<v Speaker 2>this altered my perception of food and its relationship to

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<v Speaker 2>my body. In short, food became my enemy. Unfortunately, I

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<v Speaker 2>also started to lose weight. During my first year post

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<v Speaker 2>coeliac diagnosis, I did not gain any weight despite growing

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<v Speaker 2>a few inches, and I actually remember proudly telling one

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<v Speaker 2>of my middle school friends that I hadn't gained weight

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<v Speaker 2>for an entire year. I was twelve, and I was

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<v Speaker 2>so proud of that. I also grew really self conscious

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<v Speaker 2>about my eating habits. I hated having to ask for

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<v Speaker 2>accommodations in restaurants or went over at a friend's house

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<v Speaker 2>because I didn't want people to perceive my body as

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<v Speaker 2>a problem, and I so strongly associated my body with

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<v Speaker 2>celiac that any sort of conversation about food was immensely stressful. Again,

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<v Speaker 2>while siliac disease did not necessarily cause my fractured relationship

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<v Speaker 2>with food, it made it so much easier for me

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<v Speaker 2>to continue to view food as my enemy. When I

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<v Speaker 2>went to college, Celiac became even more problematic. As with

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<v Speaker 2>many people with as many people with food allergies and

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<v Speaker 2>intolerances will know, colleges don't necessarily have the best reputation

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<v Speaker 2>for dietary accommodations. The freshman fifteen, which is in and

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<v Speaker 2>of itself a wildly problematic term, did not happen to me. Instead,

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<v Speaker 2>I lost weight. I had to walk about ten minutes

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<v Speaker 2>to get to the nearest campus dining hall, and then

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<v Speaker 2>the only option for me was rice and bland vegetables.

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<v Speaker 2>It was really easy to skip meals and supplant that

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<v Speaker 2>with going to the gym, and I became anorexic. This

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<v Speaker 2>continued through COVID, when suddenly I was living back home

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<v Speaker 2>and cooking my own meals, I rapidly gained weight. Within

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<v Speaker 2>the first few months of lockdown, which in and of

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<v Speaker 2>itself was terrifying. But that's what happened when I finally

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<v Speaker 2>started eating three meals a day and making food that

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<v Speaker 2>I actually wanted to eat. It's been about three years

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<v Speaker 2>since I was able to acknowledge how much Celiac disease

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<v Speaker 2>negatively affected my relationship with food. I had to see

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<v Speaker 2>a therapist that specialized in eating disorders, as well as

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<v Speaker 2>a dietician who had experienced working with clients like me

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<v Speaker 2>who had food intolerances. I would love to say that

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<v Speaker 2>this all immediately solved my problems, but that wouldn't be true.

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<v Speaker 2>I am, however, better at eating gluten free meals that

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<v Speaker 2>are filling and nutritious, and although it's not perfect, I

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<v Speaker 2>do have a better relationship with food now than I

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<v Speaker 2>did as a teenager. When I was first diagnosed with Celiac,

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<v Speaker 2>it seemed like a relatively easy thing to treat. I

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<v Speaker 2>thought all I had to do was stop eating bread,

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<v Speaker 2>and I wasn't the only one who thought this. I

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<v Speaker 2>actually remember people sort of brushing my diagnosis off or

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<v Speaker 2>saying that they were thinking of going gluten free to

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<v Speaker 2>lose weight. After all, I was diagnosed with Celiac right

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<v Speaker 2>when it became a sort of trendy dieting fad. I

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<v Speaker 2>didn't realize how much it would influence my entire understanding

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<v Speaker 2>of food as a necessary component of my life that

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<v Speaker 2>had seemingly become very, very evil. I would love to

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<v Speaker 2>see more support offered for children, especially girls, who are

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<v Speaker 2>diagnosed with food related intolerances and diseases at young age.

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<v Speaker 2>With Celiac specifically, it's never just bread that you have

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<v Speaker 2>to cut out of your diet. Rather, the diagnosis means

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<v Speaker 2>an entire shift in your understanding of food as the

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<v Speaker 2>thing that is supposed to help you but seemingly only

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<v Speaker 2>manages to hurt you instead.

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<v Speaker 1>Becca, thank you so much for sharing your story with us.

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<v Speaker 1>It's there are just so many important aspects that no

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<v Speaker 1>matter how much research you can do, it just doesn't

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<v Speaker 1>like the lived experience and learning about that is so important.

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<v Speaker 1>So thank you.

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<v Speaker 3>We really really appreciate it so much.

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<v Speaker 1>We do. Hi. I'm Aaron Welsh.

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<v Speaker 3>And I'm Erin Alman Updike.

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<v Speaker 1>And this is this podcast will kill You.

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<v Speaker 3>Today we are talking about Celiac disease.

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<v Speaker 1>We are, indeed, I'm.

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<v Speaker 3>Excited nervous about this one.

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<v Speaker 1>Why nervous?

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<v Speaker 3>I think just because it's so complicated, Like the biology

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<v Speaker 3>is more complicated than I even realized, and so I'm

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<v Speaker 3>nervous to explain it.

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<v Speaker 1>Well, well, I think you're going to do a great job,

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<v Speaker 1>as you always do, and we're going to learn more

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<v Speaker 1>than we knew at the beginning of this episode more

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<v Speaker 1>than Yeah. Also always yeah, I am really excited for

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<v Speaker 1>this one too. I feel like, not only is it

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<v Speaker 1>sort of just like us getting back into the groove

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<v Speaker 1>of our you know, regular format, which yeah, but also

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<v Speaker 1>I really enjoyed doing the non traditional format anyway. But

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<v Speaker 1>this is a really interesting topic with so much to

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<v Speaker 1>unpack in terms of evolution, in terms of diet culture,

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<v Speaker 1>in terms of stuff like that, and like I just

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<v Speaker 1>as a forewarning, I'm not going to get into every

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<v Speaker 1>last bit of all of that. But but also Celiac

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<v Speaker 1>is just a really fascinating topic. There is really so

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<v Speaker 1>much to unpack, and I don't know really anything about

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<v Speaker 1>the biology, as per usual, and so I'm excited to tell.

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<v Speaker 3>Me about it. I know nothing about the history.

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<v Speaker 1>Well, but before we do all of that, I suppose

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<v Speaker 1>we should probably do Quarantini. It's Quarantina time, for sure.

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<v Speaker 3>What are we drinking? This week, we're drinking no grain,

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<v Speaker 3>no pain. Get it because Celiac cluton. You'll get we'll

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<v Speaker 3>get it. We all get it.

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<v Speaker 1>I am so proud of the name for this drink.

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<v Speaker 3>It's a good one, it really is.

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<v Speaker 1>I love it. And also the recipe is delicious. Right,

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<v Speaker 1>It's basically a rhubarb mohido, So you know you've got

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<v Speaker 1>like rubarb mint lime juice rum, maybe a little bit

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<v Speaker 1>of like orange liqueur.

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<v Speaker 3>Yeah, fantastic. You can find the full recipe for that

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<v Speaker 3>quarantini as well as our non alcoholic plusy Burta on

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<v Speaker 3>our website This podcast will kill You dot com and

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<v Speaker 3>on all of our social media channels. Do you follow

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<v Speaker 3>us there? Check us out. We've got recipes.

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<v Speaker 1>We do have recipes. You should definitely follow us there.

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<v Speaker 1>On our website you can find all sorts of cool

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<v Speaker 1>things like transcripts, like links to merch links to our

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<v Speaker 1>bookshop dot org affiliate account, our Goodreads list, music by Bloodmobile,

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<v Speaker 1>a first hand account form, a contact us form. I mean,

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<v Speaker 1>there's just some good stuff you can find, so check

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<v Speaker 1>it out.

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<v Speaker 3>Check it out, check it out. Go there.

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<v Speaker 1>Can we learn about Celiac disease? Now?

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<v Speaker 3>I would love to let's take a quick break and

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<v Speaker 3>get into the biology of it. I struggle a little

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<v Speaker 3>bit with how to structure this biology erin because there

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<v Speaker 3>is a lot of detail that I could potentially get into,

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<v Speaker 3>like very nitty gritty biology. But so let's start from

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<v Speaker 3>the very beginning, shall we.

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<v Speaker 1>Let's do it?

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<v Speaker 3>What actually is coeliac disease? Like when someone says those words,

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<v Speaker 3>what do those words mean? Really? Celiac disease is an

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<v Speaker 3>autoimmune disease. It is an autoimmune disorder. We've covered autoimmune

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<v Speaker 3>disorders on this podcast before, and we'll get into the

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<v Speaker 3>specifics of like what the autoimmunity is in coeliac disease.

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<v Speaker 3>But at its core, it is your body attacking itself. First,

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<v Speaker 3>your body starts attacking gluten and in so doing, it

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<v Speaker 3>creates this inflammatory state that ends up killing a bunch

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<v Speaker 3>of your small intestine cells. That's like the end result.

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<v Speaker 3>So let's get into the steps of how kind of

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<v Speaker 3>this all happens. And to do that, I think we

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<v Speaker 3>have to start with, like what is gluten.

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<v Speaker 1>Aaron, what the heck is gluten?

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<v Speaker 3>Like?

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<v Speaker 1>I didn't even think to look at when people learned

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<v Speaker 1>what gluten was, but I feel like it was the

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<v Speaker 1>eighteen hundreds. I don't know. But anyway, like what is gluten? Yeah,

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<v Speaker 1>great question.

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<v Speaker 3>So gluten is a protein kind of, it's not like

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<v Speaker 3>a protein. It's a combination of multiple types of proteins.

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<v Speaker 3>So specifically, gluten is combinations of gleodins and glutenins. These

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<v Speaker 3>are two different types of proteins that together make up gluten,

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<v Speaker 3>which really is what makes springy bread delicious, right. It's

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<v Speaker 3>the stretchy, stringy bits that you get in wheat that

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<v Speaker 3>gives bread that chew if you're eating bread. When it

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<v Speaker 3>comes to celiac, it turns out that it's one part

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<v Speaker 3>of this gluten complex, specifically the gleodin proteins, and there's

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<v Speaker 3>different subtypes that people react to in celiac disease. And

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<v Speaker 3>it's also a different subset of these gleodins that if

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<v Speaker 3>you have a wheat allergy that you end up reacting

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<v Speaker 3>to in a different way. Allergies are totally different than autoimmunity,

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<v Speaker 3>so fascinating. And there's an enzyme in our body that

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<v Speaker 3>will become important later called TTG or tissue trans glutaminase

0:13:19.400 --> 0:13:22.120
<v Speaker 3>that helps to break down these proteins in our guts,

0:13:22.200 --> 0:13:26.560
<v Speaker 3>and this becomes important in coeliac because spoilers, this is

0:13:26.600 --> 0:13:30.400
<v Speaker 3>the enzyme that we end up making auto antibodies against.

0:13:30.760 --> 0:13:31.559
<v Speaker 1>Huh Okay.

0:13:32.320 --> 0:13:36.200
<v Speaker 3>So, these gleodin and glutenin proteins that make up gluten.

0:13:36.240 --> 0:13:39.800
<v Speaker 3>They're found in wheat, and there are other really similar

0:13:39.840 --> 0:13:43.480
<v Speaker 3>peptides that are found in rye and barley, and they're

0:13:43.520 --> 0:13:47.280
<v Speaker 3>similar enough that nowadays they're kind of lumped under this

0:13:47.440 --> 0:13:51.040
<v Speaker 3>category of gluten. And so that's why people with celiac

0:13:51.080 --> 0:13:56.600
<v Speaker 3>have to avoid wheat, rye, and barley. Oats make another

0:13:56.760 --> 0:14:00.280
<v Speaker 3>very similar protein, but it generally doesn't cross reaction with

0:14:00.320 --> 0:14:03.720
<v Speaker 3>the same antibodies as glutens. So even though it's similar,

0:14:04.120 --> 0:14:06.440
<v Speaker 3>it turns out that most of the time, oats are

0:14:06.440 --> 0:14:10.439
<v Speaker 3>pretty well tolerated and considered safe for people with celiac.

0:14:10.840 --> 0:14:13.360
<v Speaker 3>I'm not your doctor. If you have celiac, please talk

0:14:13.400 --> 0:14:16.760
<v Speaker 3>to your guest ventrologists, et cetera. But yeah, so that

0:14:17.280 --> 0:14:20.080
<v Speaker 3>is what gluten is. It's just like these combinations of

0:14:20.120 --> 0:14:23.720
<v Speaker 3>proteins that are present in some of these grains that

0:14:24.600 --> 0:14:28.760
<v Speaker 3>why do they make a person with celiac start attacking gluten?

0:14:28.840 --> 0:14:31.600
<v Speaker 3>That doesn't make sense. Why would that happen.

0:14:32.120 --> 0:14:33.400
<v Speaker 1>Why let's talk about it.

0:14:35.120 --> 0:14:39.480
<v Speaker 3>So as this is an autoimmune disease, the main underlying

0:14:39.560 --> 0:14:44.080
<v Speaker 3>issue in coeliac, like other autoimmune diseases that we've talked about,

0:14:44.080 --> 0:14:48.280
<v Speaker 3>like lupus et cetera, is the formation of these auto antibodies,

0:14:48.760 --> 0:14:52.000
<v Speaker 3>And in Celiac, you start making these auto antibodies against

0:14:52.080 --> 0:14:58.280
<v Speaker 3>these gliodin proteins in gluten. But to really get into

0:14:58.560 --> 0:15:02.400
<v Speaker 3>the nitty gritty of like why this ends up triggering

0:15:02.920 --> 0:15:05.960
<v Speaker 3>the amount of disorder that it does, we have to

0:15:05.960 --> 0:15:10.640
<v Speaker 3>also understand the genetics that play into celiac, because with

0:15:10.800 --> 0:15:16.680
<v Speaker 3>Celiac disease, the genetics become super super important. Over ninety

0:15:16.760 --> 0:15:19.440
<v Speaker 3>nine and I think it's really close to one hundred percent,

0:15:19.560 --> 0:15:22.080
<v Speaker 3>but all of the statistics just say, like over ninety

0:15:22.160 --> 0:15:25.880
<v Speaker 3>nine percent of people with Celiac have one of two

0:15:26.400 --> 0:15:33.120
<v Speaker 3>HLA markers HLA DQ two and HLA DQ eight. What

0:15:33.160 --> 0:15:36.360
<v Speaker 3>do those mean? Because they're all over the Celiac literature.

0:15:36.160 --> 0:15:39.880
<v Speaker 1>Dairy queen one and dairy queen eight. What is it? Oh,

0:15:39.920 --> 0:15:43.800
<v Speaker 1>dairy queen two, Dry queen eight, Like, what type of

0:15:43.880 --> 0:15:44.600
<v Speaker 1>blizzard are.

0:15:44.480 --> 0:15:49.560
<v Speaker 3>You getting here? Yeah? No, let's let's talk about what

0:15:49.640 --> 0:15:52.200
<v Speaker 3>is an HLA have we talked about HLA ever on

0:15:52.240 --> 0:15:53.400
<v Speaker 3>this podcast. I don't think that we.

0:15:53.400 --> 0:15:56.080
<v Speaker 1>Have, you know, I don't think that we have.

0:15:56.720 --> 0:15:59.440
<v Speaker 3>Yeah, but we may have. This why I ended up

0:15:59.440 --> 0:16:02.840
<v Speaker 3>getting nervous because this is like a lot oh gosh.

0:16:02.920 --> 0:16:05.560
<v Speaker 1>I also went down a little bit of the HLA

0:16:05.640 --> 0:16:07.960
<v Speaker 1>rabbit hole, and then I quickly was like no, no,

0:16:08.240 --> 0:16:11.320
<v Speaker 1>like turn around, you can't do this. This is not

0:16:12.920 --> 0:16:15.120
<v Speaker 1>I mean, we're not going to drop my immunology class

0:16:15.120 --> 0:16:16.000
<v Speaker 1>in college, so.

0:16:18.040 --> 0:16:19.600
<v Speaker 3>We're not going to get two into the weeds. But

0:16:19.640 --> 0:16:21.840
<v Speaker 3>I do think that it's a really interesting and important

0:16:21.880 --> 0:16:25.320
<v Speaker 3>part of Celiac disease. So what our HLA? When you

0:16:25.360 --> 0:16:28.320
<v Speaker 3>hear these words, what does this mean? HLA stands for

0:16:28.440 --> 0:16:32.160
<v Speaker 3>human leukocyte anigen. These are just proteins. We all make

0:16:32.200 --> 0:16:34.680
<v Speaker 3>a bunch of different HLA proteins. We have them in

0:16:34.720 --> 0:16:39.160
<v Speaker 3>our bodies. They are expressed on the surface of a

0:16:39.200 --> 0:16:44.200
<v Speaker 3>whole bunch of our cells, including our antigen presenting cells.

0:16:44.720 --> 0:16:48.520
<v Speaker 3>We talked about anigen presenting cells way back in Our

0:16:48.600 --> 0:16:54.640
<v Speaker 3>Vaccines episode season two. Yeah, it's been a minute, but

0:16:54.720 --> 0:16:59.120
<v Speaker 3>these are cells that help our immune system by bringing

0:16:59.200 --> 0:17:03.120
<v Speaker 3>stuff that they find to are lymph nodes or other

0:17:03.200 --> 0:17:06.800
<v Speaker 3>areas where a bunch of immune cells are congregating, and

0:17:06.840 --> 0:17:11.480
<v Speaker 3>they present stuff to our immune cells specifically like our

0:17:11.600 --> 0:17:15.199
<v Speaker 3>T cells and our B cells to activate them to

0:17:15.359 --> 0:17:19.439
<v Speaker 3>start an inflammatory reaction. So they are the cells that

0:17:19.520 --> 0:17:22.080
<v Speaker 3>go out and gather up things that they find that

0:17:22.240 --> 0:17:26.840
<v Speaker 3>might be foreign particles in our body, viruses, proteins, gluten,

0:17:26.920 --> 0:17:29.720
<v Speaker 3>whatever it is, and they bring them and say here,

0:17:29.800 --> 0:17:31.920
<v Speaker 3>I have presented something to you. Tell me if it's

0:17:32.000 --> 0:17:36.240
<v Speaker 3>dangerous or not right, and then then our T cells,

0:17:36.240 --> 0:17:40.679
<v Speaker 3>which are British, always, oh always react to those things

0:17:40.760 --> 0:17:45.520
<v Speaker 3>if necessary. Everyone has a variety of HLA proteins. You

0:17:45.640 --> 0:17:48.520
<v Speaker 3>get half of your HLA proteins from your mom, half

0:17:48.600 --> 0:17:51.879
<v Speaker 3>from your dad, and then that makes up your HLA component.

0:17:52.680 --> 0:17:55.879
<v Speaker 3>The two that are involved in Celiac, Dq two and

0:17:55.960 --> 0:18:02.119
<v Speaker 3>Dq eight happen to have an affinity for glutent specifically

0:18:02.160 --> 0:18:07.160
<v Speaker 3>for gleodin proteins, so they have the ability in your

0:18:07.240 --> 0:18:10.600
<v Speaker 3>guts because remember from our tonsils episode that our guts

0:18:10.680 --> 0:18:15.719
<v Speaker 3>have their own entire immune system. So these HLA proteins

0:18:15.800 --> 0:18:18.840
<v Speaker 3>in our guts find some of this gluten bring it

0:18:18.880 --> 0:18:22.120
<v Speaker 3>over to pire's patches in our guts where immune cells

0:18:22.119 --> 0:18:25.600
<v Speaker 3>are congregating, and they're like, hey, T cells, what should

0:18:25.600 --> 0:18:29.679
<v Speaker 3>we do with this? And if you have Celiac disease,

0:18:29.800 --> 0:18:33.440
<v Speaker 3>or if you develop Celiac disease, your T cells are

0:18:33.440 --> 0:18:36.560
<v Speaker 3>going to see that gleodin protein and be like we'll

0:18:36.560 --> 0:18:41.720
<v Speaker 3>I'll destroy them and go hogwild.

0:18:42.040 --> 0:18:43.920
<v Speaker 1>Tell me more about Pire's patches.

0:18:44.400 --> 0:18:48.879
<v Speaker 3>Oh, so, Pire's patches are kind of like the tonsils

0:18:48.920 --> 0:18:49.560
<v Speaker 3>of your guts.

0:18:50.040 --> 0:18:53.359
<v Speaker 1>I love that is a cute. How many Pire's patches

0:18:53.400 --> 0:18:57.160
<v Speaker 1>are there? Where are they located? How big are they?

0:18:57.280 --> 0:18:59.800
<v Speaker 1>What's in them? What do they do?

0:19:00.080 --> 0:19:02.800
<v Speaker 3>What are other things that they do? Yeah, it's literally

0:19:02.880 --> 0:19:05.840
<v Speaker 3>like your tonsils. It's literally like little patches of immune cells.

0:19:05.920 --> 0:19:07.880
<v Speaker 3>And so it's where your T cells, where your B cells,

0:19:07.880 --> 0:19:10.400
<v Speaker 3>and where other immune cells are congregating. I have no

0:19:10.480 --> 0:19:12.640
<v Speaker 3>idea how many you have or how big they are.

0:19:13.880 --> 0:19:18.560
<v Speaker 3>They're mostly throughout your small intestine, and my histology classes

0:19:18.600 --> 0:19:20.720
<v Speaker 3>are going to be failing me on more details than that,

0:19:21.280 --> 0:19:23.040
<v Speaker 3>because they might be in your large intestine too, but

0:19:23.119 --> 0:19:26.840
<v Speaker 3>I don't remember. But they're in your guts.

0:19:27.320 --> 0:19:32.760
<v Speaker 1>I have an off topic question about intestines. Yeah, can

0:19:32.800 --> 0:19:35.280
<v Speaker 1>you tell me a little bit just like a very

0:19:35.320 --> 0:19:39.080
<v Speaker 1>simple explanation between the different parts of your intestines and

0:19:39.119 --> 0:19:39.720
<v Speaker 1>what they do.

0:19:42.119 --> 0:19:45.040
<v Speaker 3>Are you really going to do this to me right now?

0:19:45.480 --> 0:19:45.720
<v Speaker 2>Okay?

0:19:45.760 --> 0:19:46.800
<v Speaker 1>Okay, you don't have to.

0:19:49.040 --> 0:19:52.200
<v Speaker 3>I mean so okay. If you start from your mouth,

0:19:52.840 --> 0:19:56.000
<v Speaker 3>your mouth goes to your esophagus, right you're like oral

0:19:56.040 --> 0:19:59.000
<v Speaker 3>FARINGX goes down into your esophagus, It goes through your

0:19:59.000 --> 0:20:01.920
<v Speaker 3>food is going to go through your esophageal sphincter into

0:20:01.960 --> 0:20:05.600
<v Speaker 3>your stomach, where it's going to mostly be digested. From

0:20:05.640 --> 0:20:08.000
<v Speaker 3>your stomach, it's going to pass through another sphincter into

0:20:08.040 --> 0:20:11.320
<v Speaker 3>your duodenum, which is the first part of your small intestine.

0:20:11.760 --> 0:20:14.320
<v Speaker 3>Then your small intestine is super long. It's like, I

0:20:14.320 --> 0:20:16.359
<v Speaker 3>don't know, over twenty five feet long or something. It

0:20:16.400 --> 0:20:19.040
<v Speaker 3>wiggles back and forth in like the whole center of

0:20:19.080 --> 0:20:22.280
<v Speaker 3>your abdomen. If you look at like a picture of guts,

0:20:22.359 --> 0:20:25.800
<v Speaker 3>it's the wiggly part in the whole center. Your small

0:20:25.800 --> 0:20:29.080
<v Speaker 3>intestine has multiple other parts. There's like the duodenum and

0:20:29.080 --> 0:20:31.520
<v Speaker 3>then the jujunum, and then it goes down into the ilium,

0:20:31.560 --> 0:20:34.080
<v Speaker 3>which is the last part of your small intestine. Your

0:20:34.119 --> 0:20:37.320
<v Speaker 3>small intestine is mostly responsible for like the continuation of

0:20:37.359 --> 0:20:40.280
<v Speaker 3>digestion in the first part and then absorption. All of

0:20:40.280 --> 0:20:43.640
<v Speaker 3>your nutrient absorption is going to happen throughout your small intestine,

0:20:44.080 --> 0:20:47.159
<v Speaker 3>and then it passes through the iliosecal valve, which is

0:20:47.200 --> 0:20:49.320
<v Speaker 3>the last part of your small intestine, and that goes

0:20:49.320 --> 0:20:52.880
<v Speaker 3>into your colon. That happens right in your right lower

0:20:52.960 --> 0:20:56.600
<v Speaker 3>quadrant where your appendix is, because that's like a little

0:20:56.640 --> 0:20:59.840
<v Speaker 3>beep that hangs off the edge kind of where your

0:21:00.119 --> 0:21:03.879
<v Speaker 3>intestine and large intestine combined kind of. And then your

0:21:03.960 --> 0:21:07.399
<v Speaker 3>large intestine goes up your ascending colon on the right side,

0:21:07.440 --> 0:21:10.280
<v Speaker 3>and then it goes across the top that's called your

0:21:10.280 --> 0:21:14.239
<v Speaker 3>transverse colon, and then down your descending colon on your

0:21:14.320 --> 0:21:17.560
<v Speaker 3>left hand side, and then it wiggles around and that's

0:21:17.600 --> 0:21:19.960
<v Speaker 3>called your sigmoid colon, and then into your rectum and

0:21:20.000 --> 0:21:25.360
<v Speaker 3>out your butt. Your colon mostly is reabsorbing water. That's

0:21:25.400 --> 0:21:28.240
<v Speaker 3>like the main function of what's happening in your colon.

0:21:29.040 --> 0:21:31.600
<v Speaker 3>There's some nutrients that also get reabsorbed there in your

0:21:31.600 --> 0:21:33.480
<v Speaker 3>colon as well, but that's like the main thing that's

0:21:33.520 --> 0:21:36.320
<v Speaker 3>happening throughout your colon. Does that answer your question?

0:21:36.400 --> 0:21:39.199
<v Speaker 1>That was beautiful? Thank you, first of all, thank you

0:21:39.280 --> 0:21:41.640
<v Speaker 1>for such a It was really impressive that you really

0:21:41.640 --> 0:21:46.400
<v Speaker 1>love I know everything about this is perfect. Secondly, thank

0:21:46.400 --> 0:21:50.480
<v Speaker 1>you for always answering my ridiculous question like that.

0:21:50.760 --> 0:21:52.920
<v Speaker 3>I love your questions. I just didn't make me nervous

0:21:53.000 --> 0:21:54.840
<v Speaker 3>because I feel like I'm going to get it all wrong.

0:21:55.760 --> 0:21:56.480
<v Speaker 1>I wouldn't know.

0:21:57.880 --> 0:22:02.440
<v Speaker 3>That's the best part, but that is it is important

0:22:02.480 --> 0:22:06.439
<v Speaker 3>because what we'll see in coeliac is that coeliac is

0:22:06.440 --> 0:22:10.400
<v Speaker 3>a disease that affects your small intestine. And so as

0:22:10.440 --> 0:22:11.919
<v Speaker 3>we'll see when we get to like, what are the

0:22:11.920 --> 0:22:15.160
<v Speaker 3>symptoms that you see with celiac, They're a lot going

0:22:15.200 --> 0:22:18.919
<v Speaker 3>to revolve around the inability to absorb the nutrients that

0:22:18.960 --> 0:22:21.120
<v Speaker 3>you need to because of the damage that is done

0:22:21.160 --> 0:22:25.200
<v Speaker 3>to your small intestine. Okay, so getting back all the

0:22:25.240 --> 0:22:28.600
<v Speaker 3>way too, I think we were at HLA still No, yeah,

0:22:28.640 --> 0:22:35.880
<v Speaker 3>we were not even in the duodenum. No, so your

0:22:36.560 --> 0:22:39.960
<v Speaker 3>T cells are going to respond and start causing damage

0:22:40.119 --> 0:22:43.760
<v Speaker 3>to your small intestine. It's a little bit more complicated

0:22:43.840 --> 0:22:49.399
<v Speaker 3>than just gluten being presented because I mentioned already this

0:22:49.560 --> 0:22:52.920
<v Speaker 3>enzyme called tissue trans glutaminase. And this is where I'm

0:22:52.960 --> 0:22:55.040
<v Speaker 3>not going to get too too deep into the weeds,

0:22:55.040 --> 0:22:58.320
<v Speaker 3>because while there is a lot that we know about

0:22:58.320 --> 0:23:01.480
<v Speaker 3>the nitty gritty path of physiology that's involved here in

0:23:01.520 --> 0:23:06.840
<v Speaker 3>this intestinal damage that's mediated by this autoimmunity. I'll link

0:23:06.880 --> 0:23:09.280
<v Speaker 3>to a paper about it. It gets just too detailed

0:23:09.280 --> 0:23:12.600
<v Speaker 3>for us here. But what is important is that there's

0:23:12.640 --> 0:23:16.399
<v Speaker 3>this enzyme called tissue transglutaminase. This is something that we

0:23:16.480 --> 0:23:19.640
<v Speaker 3>all have that helps to break down gluten in our bodies.

0:23:20.320 --> 0:23:23.920
<v Speaker 3>But what happens in the case of celiac disease is

0:23:23.960 --> 0:23:27.560
<v Speaker 3>that as gluten is bound to TTG, what ends up

0:23:27.560 --> 0:23:32.879
<v Speaker 3>happening is that it makes this gluten protein even more

0:23:33.040 --> 0:23:38.480
<v Speaker 3>available for presentation to T cells, and then those T

0:23:38.680 --> 0:23:39.439
<v Speaker 3>cells that are.

0:23:39.320 --> 0:23:41.640
<v Speaker 1>Like this is foreign, will destroy.

0:23:41.200 --> 0:23:47.280
<v Speaker 3>It ends up also making antibodies against TTG, and that

0:23:47.440 --> 0:23:50.280
<v Speaker 3>is one of the main auto antibodies that we see,

0:23:50.320 --> 0:23:55.720
<v Speaker 3>antibodies against your own tissue transglutaminase proteins that then end

0:23:55.800 --> 0:24:01.240
<v Speaker 3>up triggering this whole cascade of immune reactions that leads

0:24:01.280 --> 0:24:03.960
<v Speaker 3>to the damage that we see to the small intestine

0:24:04.040 --> 0:24:05.000
<v Speaker 3>in coeliac disease.

0:24:05.359 --> 0:24:10.120
<v Speaker 1>Does that make sense, victims of our own immune efficiency?

0:24:10.520 --> 0:24:11.720
<v Speaker 3>Exactly? Exactly?

0:24:12.000 --> 0:24:15.800
<v Speaker 1>Okay, So basically what happens is that gluten is you

0:24:15.840 --> 0:24:19.320
<v Speaker 1>eat gluten, it's coming through something presents it to your

0:24:19.359 --> 0:24:22.000
<v Speaker 1>T cells, and the T cells go attack everything, and

0:24:22.040 --> 0:24:25.560
<v Speaker 1>then there's a bunch of collateral damage from the T

0:24:25.680 --> 0:24:29.320
<v Speaker 1>cells attacking not only the cells presenting gluten, but also

0:24:29.359 --> 0:24:30.840
<v Speaker 1>the enzymes presenting gluten.

0:24:31.400 --> 0:24:35.760
<v Speaker 3>Yeah, essentially essentially that So, really, if we step back

0:24:35.800 --> 0:24:39.080
<v Speaker 3>and look very very big picture, how does someone end

0:24:39.200 --> 0:24:42.800
<v Speaker 3>up getting celiac disease. There's three main things that have

0:24:42.840 --> 0:24:45.520
<v Speaker 3>to happen. One, you have to be born with this

0:24:45.600 --> 0:24:48.960
<v Speaker 3>specific HLA type right, either Dq two or Dq eight,

0:24:49.240 --> 0:24:51.240
<v Speaker 3>and that's going to mean that you're going to happen

0:24:51.280 --> 0:24:54.399
<v Speaker 3>to be really good at presenting gluten in the first place.

0:24:55.240 --> 0:24:57.840
<v Speaker 3>Number Two, you then have to be exposed to gluten.

0:24:58.440 --> 0:25:03.159
<v Speaker 3>So what's really in resting about coeliac disease compared to

0:25:03.359 --> 0:25:07.800
<v Speaker 3>most other autoimmune diseases is that we know that specific

0:25:07.920 --> 0:25:11.920
<v Speaker 3>trigger so specifically, I guess not to use the same

0:25:11.920 --> 0:25:15.760
<v Speaker 3>word over and over, But for most autoimmune diseases, we think,

0:25:15.920 --> 0:25:18.720
<v Speaker 3>or we know in some cases that there are environmental

0:25:18.720 --> 0:25:23.600
<v Speaker 3>exposures as well as genetic susceptibility, right, But with celiac,

0:25:23.720 --> 0:25:27.680
<v Speaker 3>we can pinpoint that gluten is necessary for the development

0:25:27.680 --> 0:25:33.520
<v Speaker 3>of coeliac disease, and gluten is the trigger that continues

0:25:33.640 --> 0:25:38.120
<v Speaker 3>to perpetuate and cause damage. But it's not just those

0:25:38.119 --> 0:25:42.160
<v Speaker 3>two things. It's not just this genetic susceptibility and exposure

0:25:42.200 --> 0:25:47.359
<v Speaker 3>to gluten. There's also a third component, something else, And

0:25:47.400 --> 0:25:52.000
<v Speaker 3>that's something else we don't fully understand. It's involved with

0:25:52.280 --> 0:25:58.360
<v Speaker 3>tissue transglutaminase and creating these auto antibodies against tissue transglutaminase

0:25:58.440 --> 0:26:01.879
<v Speaker 3>and other enzymes as well. It's just this one, but

0:26:01.920 --> 0:26:06.280
<v Speaker 3>there's some other trigger that has to happen that then

0:26:06.480 --> 0:26:11.440
<v Speaker 3>leads to the eventual presentation and development of auto antibodies

0:26:11.440 --> 0:26:15.280
<v Speaker 3>against gluten but also against your own cells and your

0:26:15.320 --> 0:26:19.840
<v Speaker 3>own enzymes that end in this immune activation and damage

0:26:19.840 --> 0:26:23.840
<v Speaker 3>to the small intestine. Now that third point, the trigger

0:26:24.560 --> 0:26:27.320
<v Speaker 3>besides gluten, we don't know what that is. We don't

0:26:27.400 --> 0:26:31.399
<v Speaker 3>understand it. Something like twenty to thirty percent of people

0:26:31.560 --> 0:26:34.880
<v Speaker 3>have these various HLA types DQ two and DQ eight.

0:26:35.640 --> 0:26:40.040
<v Speaker 3>Almost everyone is exposed to gluten. Right. Gluten is in wheat,

0:26:40.119 --> 0:26:44.280
<v Speaker 3>rye and barley across the entire globe. Populations depend on

0:26:44.400 --> 0:26:46.359
<v Speaker 3>these grains, and I know erin you'll talk a little

0:26:46.400 --> 0:26:49.400
<v Speaker 3>bit more about that from an evolutionary perspective, but it's

0:26:49.440 --> 0:26:52.199
<v Speaker 3>a very small subset of people who then end up

0:26:52.240 --> 0:26:56.240
<v Speaker 3>developing seliac disease. So there is some other environmental trigger

0:26:56.280 --> 0:26:59.439
<v Speaker 3>that we don't fully understand. There are a lot of

0:26:59.480 --> 0:27:03.080
<v Speaker 3>ideas on what this can be. There's some data that

0:27:03.119 --> 0:27:08.760
<v Speaker 3>perhaps exposure to gastrointestinal infections, including rotavirus, might be one

0:27:08.760 --> 0:27:10.680
<v Speaker 3>of those triggers or one of those things that puts

0:27:10.720 --> 0:27:16.040
<v Speaker 3>you at higher risk spoilers rotavirus vaccination might help protect

0:27:16.040 --> 0:27:17.760
<v Speaker 3>against the development of coeliac disease.

0:27:17.920 --> 0:27:19.480
<v Speaker 1>I was just going to say, and do we have

0:27:19.560 --> 0:27:23.080
<v Speaker 1>like before after data to suggest that or like at

0:27:23.160 --> 0:27:24.360
<v Speaker 1>least regional really.

0:27:24.359 --> 0:27:28.240
<v Speaker 3>Know, but there's some evidence in some studies that vaccination

0:27:28.359 --> 0:27:33.959
<v Speaker 3>might be slightly protective, especially in high risk populations. Okay, yeah,

0:27:34.000 --> 0:27:38.679
<v Speaker 3>but there is something else right, And altogether, what that

0:27:38.800 --> 0:27:42.159
<v Speaker 3>means is that we don't fully understand how to prevent

0:27:42.280 --> 0:27:44.560
<v Speaker 3>celiac disease at this point, which is really.

0:27:44.440 --> 0:28:01.920
<v Speaker 1>Important since we don't know what the trigger is. That's

0:28:01.920 --> 0:28:04.040
<v Speaker 1>probably all over the place in terms of when people

0:28:04.080 --> 0:28:06.879
<v Speaker 1>first recognize symptoms or when people get diagnosed, and then

0:28:06.920 --> 0:28:09.600
<v Speaker 1>there's stories about how long it can take some times

0:28:09.600 --> 0:28:12.920
<v Speaker 1>to get diagnosis. So tell me about the symptoms. How

0:28:12.920 --> 0:28:15.000
<v Speaker 1>does one get diagnosed, et cetera.

0:28:16.040 --> 0:28:19.720
<v Speaker 3>Yeah, so a lot of people think of celiac disease

0:28:19.720 --> 0:28:22.560
<v Speaker 3>as an intestinal disease, and I said already, like, the

0:28:22.560 --> 0:28:25.239
<v Speaker 3>main thing is it's going to cause damage to the

0:28:25.280 --> 0:28:27.960
<v Speaker 3>cells of your small intestine. So it is true that

0:28:28.119 --> 0:28:31.119
<v Speaker 3>the small intestine is the main site of disease and

0:28:31.160 --> 0:28:36.199
<v Speaker 3>pathology and therefore also symptoms. But because this is an

0:28:36.200 --> 0:28:39.320
<v Speaker 3>autoimmune disease, it also shouldn't be too far fetched to

0:28:39.600 --> 0:28:44.200
<v Speaker 3>convince everyone that there are also extra intestinal manifestations whole

0:28:44.240 --> 0:28:47.360
<v Speaker 3>body disease. So let's get into what this all can

0:28:47.400 --> 0:28:52.440
<v Speaker 3>look like. The most classic quote unquote symptom that's associated

0:28:52.440 --> 0:28:56.520
<v Speaker 3>with celiac disease, and it's also now called classical coeliac

0:28:57.880 --> 0:29:04.320
<v Speaker 3>is diarrhea, and diarrhea can be pretty profound because again,

0:29:04.560 --> 0:29:09.280
<v Speaker 3>what's causing this diarrhea is that your small intestine kind

0:29:09.320 --> 0:29:12.760
<v Speaker 3>of gets destroyed. Like I mentioned that because of your

0:29:12.760 --> 0:29:16.360
<v Speaker 3>wonderful question, Aaron, that your small intestine is where we

0:29:16.440 --> 0:29:20.080
<v Speaker 3>have to absorb all of our nutrients. The way that

0:29:20.120 --> 0:29:23.360
<v Speaker 3>your intestine does that is they have inside. If you

0:29:23.400 --> 0:29:26.360
<v Speaker 3>look in your small intestine, these beautiful, wonderful things called

0:29:26.480 --> 0:29:31.280
<v Speaker 3>villi that are kind of like these anemone tentacles lining

0:29:31.320 --> 0:29:35.360
<v Speaker 3>your whole small intestine. They make this incredible amount of

0:29:35.520 --> 0:29:39.080
<v Speaker 3>surface area for all of that absorption to be able

0:29:39.120 --> 0:29:43.720
<v Speaker 3>to happen. In celiac disease, you develop what's called enteropathy,

0:29:43.720 --> 0:29:47.720
<v Speaker 3>which just means damage to that small intestine specifically and

0:29:48.000 --> 0:29:52.120
<v Speaker 3>blunting of these villi. These are just fancy medical words

0:29:52.160 --> 0:29:55.840
<v Speaker 3>to say that all of your beautiful gut anemonies.

0:29:55.440 --> 0:29:59.400
<v Speaker 1>Are flattened like a lawn that's been mode.

0:29:59.200 --> 0:30:02.920
<v Speaker 3>Exactly, so you can't absorb all of those nutrients. So

0:30:03.080 --> 0:30:06.360
<v Speaker 3>in addition to the diarrhea, what we can also see

0:30:06.480 --> 0:30:10.240
<v Speaker 3>is a lot of weight loss and malabsorption, and this

0:30:10.320 --> 0:30:14.000
<v Speaker 3>can lead to deficiencies in a whole variety of vitamins

0:30:14.040 --> 0:30:17.440
<v Speaker 3>and minerals that can then in turn lead to things

0:30:17.520 --> 0:30:21.240
<v Speaker 3>like anemia, and not just one type of anemia. Yes,

0:30:21.320 --> 0:30:24.040
<v Speaker 3>you can have iron deficiency anemia from not being able

0:30:24.080 --> 0:30:27.960
<v Speaker 3>to absorb iron, but also other vitamin deficiency anemia is

0:30:28.040 --> 0:30:33.480
<v Speaker 3>like B twelve deficiency, full late deficiency, and especially in kids,

0:30:33.840 --> 0:30:38.040
<v Speaker 3>and a lot of the time celiac develops in young

0:30:38.200 --> 0:30:41.000
<v Speaker 3>kids even if it's not diagnosed until they get older.

0:30:41.400 --> 0:30:44.080
<v Speaker 3>You can then see growth failure because of how much

0:30:44.160 --> 0:30:47.160
<v Speaker 3>malabsorption you have. On top of that, you can end

0:30:47.240 --> 0:30:51.080
<v Speaker 3>up with other symptoms or other entire diseases like osteoporosis,

0:30:51.320 --> 0:30:54.520
<v Speaker 3>which results from not being able to absorb enough calcium.

0:30:55.360 --> 0:30:59.480
<v Speaker 3>Another common sign is abnormal liver testing, which we don't

0:30:59.480 --> 0:31:02.840
<v Speaker 3>have an exact mechanism for, except that that TTG enzyme

0:31:02.960 --> 0:31:05.280
<v Speaker 3>is also present in the liver. So is it because

0:31:05.320 --> 0:31:07.400
<v Speaker 3>of damage to the liver from that? I'm not one

0:31:07.480 --> 0:31:10.640
<v Speaker 3>hundred percent sure. But then with all of this overall

0:31:10.680 --> 0:31:14.440
<v Speaker 3>malabsorption and literal damage to the small intestine, you can

0:31:14.480 --> 0:31:18.200
<v Speaker 3>have a lot of abdominal pain and bloating. Sometimes you

0:31:18.320 --> 0:31:22.480
<v Speaker 3>end up paradoxically having constipation because of just how much

0:31:22.560 --> 0:31:26.160
<v Speaker 3>overall damage and dysfunction and dysregulation really that we see

0:31:26.200 --> 0:31:27.080
<v Speaker 3>in the guts.

0:31:28.400 --> 0:31:31.320
<v Speaker 1>Tell me, tell me more about the diarrhea.

0:31:32.160 --> 0:31:34.600
<v Speaker 3>What more would you like to know about the diarrhea?

0:31:34.800 --> 0:31:42.080
<v Speaker 1>Is there are there characteristic diarrhea like content or frequency

0:31:42.440 --> 0:31:44.520
<v Speaker 1>or yeah?

0:31:44.720 --> 0:31:49.280
<v Speaker 3>Yeah, not really. Sometimes people can have what's called staatarrhea,

0:31:49.560 --> 0:31:53.640
<v Speaker 3>which means like fatty diarrhea, so like that very oily kind,

0:31:53.920 --> 0:31:57.600
<v Speaker 3>but it's not something that's specific. You could see like

0:31:57.640 --> 0:32:01.320
<v Speaker 3>a bloody diarrhea, but not nes necessarily. It's not like

0:32:01.480 --> 0:32:04.480
<v Speaker 3>characteristic of coeliac or anything the way that it would

0:32:04.520 --> 0:32:09.200
<v Speaker 3>be for an inflammatory bowel disease, which we'll do eventually

0:32:09.200 --> 0:32:12.360
<v Speaker 3>on this podcast, But that's something like ulstertive colitis or crones,

0:32:12.400 --> 0:32:15.200
<v Speaker 3>which is causing damage not to the small intestine but

0:32:15.280 --> 0:32:19.960
<v Speaker 3>the large intestine, asterisks, et cetera. But in general, those

0:32:19.960 --> 0:32:23.240
<v Speaker 3>are associated with more bloody diarrhea, which you would expect

0:32:23.280 --> 0:32:25.000
<v Speaker 3>to see a little bit less of with celiac, but

0:32:25.040 --> 0:32:28.440
<v Speaker 3>it's not impossible. So no, there's nothing that makes this

0:32:28.520 --> 0:32:33.320
<v Speaker 3>diarrhea special I guess or very specific. Diarrhea is a

0:32:33.360 --> 0:32:37.760
<v Speaker 3>very non specific symptom. And while it is classic, it's

0:32:37.920 --> 0:32:42.800
<v Speaker 3>not necessary to have coeliac disease. Not everyone with celiac

0:32:42.880 --> 0:32:46.600
<v Speaker 3>is going to present with diarrhea at all. And in

0:32:46.640 --> 0:32:50.320
<v Speaker 3>addition to these intestinal symptoms, there are also extra intestinal

0:32:50.320 --> 0:32:54.680
<v Speaker 3>they're outside the intestine symptoms and not just all of

0:32:54.680 --> 0:32:58.680
<v Speaker 3>those complications from malabsorption that I already mentioned right, the

0:32:58.720 --> 0:33:04.120
<v Speaker 3>osteoporosis and the there are also a few specific extra

0:33:04.160 --> 0:33:08.320
<v Speaker 3>intestinal manifestations that we see relatively commonly there's a condition

0:33:08.440 --> 0:33:13.160
<v Speaker 3>called dermatitis herpetiformis no idea where it got that name.

0:33:13.160 --> 0:33:16.800
<v Speaker 3>It's a weird name, but this is a skin blistering

0:33:17.040 --> 0:33:21.280
<v Speaker 3>condition that is associated with celiac disease, and it's directly

0:33:21.600 --> 0:33:25.320
<v Speaker 3>related to gluten consumption in someone with coeliac disease who

0:33:25.360 --> 0:33:28.840
<v Speaker 3>may not have any other symptoms that they know of

0:33:28.840 --> 0:33:33.320
<v Speaker 3>of coeliac, meaning no intestinal symptoms except for this rash.

0:33:33.360 --> 0:33:39.120
<v Speaker 3>And this rash looks like incredibly itchy, fluid filled blisters

0:33:39.120 --> 0:33:43.120
<v Speaker 3>and vesicles, mostly on like extensor surfaces, so like the

0:33:43.200 --> 0:33:46.880
<v Speaker 3>front of your legs or the back of your arms,

0:33:47.000 --> 0:33:50.240
<v Speaker 3>or on your butt or your trunk, and they're super

0:33:50.280 --> 0:33:52.800
<v Speaker 3>super itchy and look kind of like little teeny tiny

0:33:52.800 --> 0:33:56.680
<v Speaker 3>blisters everywhere. And then there are also a handful of

0:33:56.720 --> 0:34:00.880
<v Speaker 3>neurologic complications of coeliac disease, the most well known of

0:34:00.960 --> 0:34:05.120
<v Speaker 3>which is gluten ataxia. We've talked about ataxia on this

0:34:05.200 --> 0:34:09.160
<v Speaker 3>podcast before. A Taxia is a movement disorder where you

0:34:09.280 --> 0:34:14.279
<v Speaker 3>lose the ability to coordinate movements, especially walking, because of

0:34:14.400 --> 0:34:17.280
<v Speaker 3>damage to the cerebellum or the bottom part of your brain.

0:34:18.080 --> 0:34:22.279
<v Speaker 3>And this is a neurologic manifestation of coeliac disease. For

0:34:22.440 --> 0:34:27.960
<v Speaker 3>these extra intestinal manifestations, we don't fully understand them or

0:34:28.000 --> 0:34:31.320
<v Speaker 3>like why exactly are you seeing these or what exactly

0:34:31.360 --> 0:34:35.759
<v Speaker 3>is the specific like cause in consequence kind of a thing,

0:34:36.120 --> 0:34:40.120
<v Speaker 3>which is not surprising, But we do know that these

0:34:40.160 --> 0:34:44.640
<v Speaker 3>two things specifically are related to celiac disease. And then

0:34:44.680 --> 0:34:48.320
<v Speaker 3>there are other disorders or diagnoses that we might see

0:34:48.719 --> 0:34:51.920
<v Speaker 3>at higher rates in people with celiac that we don't

0:34:51.960 --> 0:34:54.360
<v Speaker 3>know if they're causal or not, and that's things like

0:34:54.440 --> 0:34:55.840
<v Speaker 3>migraines or depression.

0:34:56.440 --> 0:34:57.120
<v Speaker 1>We even can.

0:34:57.040 --> 0:35:03.000
<v Speaker 3>See recurrent pregnancy loss from undiagnosed untreated celiac, and having

0:35:03.080 --> 0:35:06.520
<v Speaker 3>untreated coeliac disease during pregnancy can result in babies that

0:35:06.560 --> 0:35:09.600
<v Speaker 3>are born small for gestational age because of growth restriction.

0:35:10.360 --> 0:35:14.600
<v Speaker 3>So celiac is not just diarrhea, And I feel like

0:35:14.640 --> 0:35:17.400
<v Speaker 3>that's really important because I think that it can sometimes

0:35:17.480 --> 0:35:21.040
<v Speaker 3>get kind of tossed aside as not a big deal

0:35:22.640 --> 0:35:25.440
<v Speaker 3>because it gets conflated with a lot of other conditions.

0:35:26.000 --> 0:35:29.800
<v Speaker 1>Right, how long does it usually take, Like do the

0:35:29.880 --> 0:35:33.600
<v Speaker 1>symptoms go from zero to sixty or is it more

0:35:33.640 --> 0:35:36.879
<v Speaker 1>of a like a slower onset, And then how does

0:35:36.920 --> 0:35:40.560
<v Speaker 1>delay and diagnosis affect sort of long term consequences and

0:35:40.800 --> 0:35:44.880
<v Speaker 1>are we good at diagnosing celiac? This is such so

0:35:44.880 --> 0:35:47.399
<v Speaker 1>many questions just sprinkling them in.

0:35:48.840 --> 0:35:52.359
<v Speaker 3>Oh, there's such good questions though, arin So it's really

0:35:52.360 --> 0:35:54.360
<v Speaker 3>interesting to try and think about, like does it go

0:35:54.440 --> 0:35:57.200
<v Speaker 3>from zero to one hundred? Like what is that kind

0:35:57.239 --> 0:36:00.319
<v Speaker 3>of time frame? The truth is that because we don't

0:36:00.360 --> 0:36:04.960
<v Speaker 3>really know at what point someone kind of loses their

0:36:05.000 --> 0:36:11.680
<v Speaker 3>tolerance to gluten and therefore develop coeliac disease. And what

0:36:11.719 --> 0:36:15.120
<v Speaker 3>I mean by that is that someone might have no

0:36:15.280 --> 0:36:18.960
<v Speaker 3>symptoms and if they are followed for long enough, let's say,

0:36:19.000 --> 0:36:20.960
<v Speaker 3>in studies where they're looking at kind of like higher

0:36:21.040 --> 0:36:25.400
<v Speaker 3>risk populations, so either someone who has a known HLA

0:36:26.239 --> 0:36:29.880
<v Speaker 3>haplotype that's associated and a first degree family relative or

0:36:29.920 --> 0:36:31.919
<v Speaker 3>something like that. Right, so they're in these studies where

0:36:31.920 --> 0:36:34.040
<v Speaker 3>they're trying to look at when do you develop celiac,

0:36:35.040 --> 0:36:39.000
<v Speaker 3>they might end up with these antibodies that we associated

0:36:39.040 --> 0:36:42.520
<v Speaker 3>with seliac disease even before they have any symptoms of

0:36:42.560 --> 0:36:46.359
<v Speaker 3>coeliac disease. On the flip side, someone might have symptoms

0:36:46.480 --> 0:36:52.000
<v Speaker 3>for years before getting a diagnosis, and then that turns

0:36:52.040 --> 0:36:54.239
<v Speaker 3>out that all of those symptoms were related to celiac,

0:36:54.760 --> 0:36:57.920
<v Speaker 3>or they might not have any symptoms, get diagnosed, and

0:36:57.960 --> 0:36:59.799
<v Speaker 3>then look back and realize, actually, no, maybe I did

0:36:59.800 --> 0:37:01.960
<v Speaker 3>have these symptoms, but I just didn't realize that they

0:37:02.000 --> 0:37:04.600
<v Speaker 3>were symptoms, if that makes sense. So there's not a

0:37:04.600 --> 0:37:07.600
<v Speaker 3>good answer really to your question. And I think that

0:37:07.600 --> 0:37:11.360
<v Speaker 3>that's part of what one of the challenges is in

0:37:11.440 --> 0:37:14.480
<v Speaker 3>trying to understand what are the points at which and

0:37:14.520 --> 0:37:17.480
<v Speaker 3>what are the real triggers aside from the genetics and

0:37:17.520 --> 0:37:20.759
<v Speaker 3>aside from the gluten that are associated with the development

0:37:20.760 --> 0:37:22.880
<v Speaker 3>of celiac disease. We don't really know, and so we

0:37:22.920 --> 0:37:26.560
<v Speaker 3>don't know when someone is going to develop disease from

0:37:26.640 --> 0:37:29.799
<v Speaker 3>celiac or not, but when it comes to how do

0:37:29.880 --> 0:37:34.080
<v Speaker 3>we end up diagnosing them. For a long time, biopsy

0:37:34.160 --> 0:37:37.160
<v Speaker 3>was considered the gold standard, and that's really to look

0:37:37.200 --> 0:37:40.920
<v Speaker 3>for those specific types of damage in the small intestine

0:37:40.960 --> 0:37:45.840
<v Speaker 3>that we see associated with celiac, both like visually and histologically.

0:37:47.080 --> 0:37:51.360
<v Speaker 3>Because biopsy is invasive and not available to everyone and

0:37:51.440 --> 0:37:55.280
<v Speaker 3>expensive and time consuming and all these things, especially for children,

0:37:56.160 --> 0:37:59.160
<v Speaker 3>people are kind of moving away from biopsy, though it

0:37:59.239 --> 0:38:02.560
<v Speaker 3>is still kind of like, especially if the diagnosis is

0:38:02.600 --> 0:38:05.800
<v Speaker 3>in question. One of the important parts of a diagnosis.

0:38:06.440 --> 0:38:08.880
<v Speaker 3>But there are other tests that are getting better and

0:38:08.920 --> 0:38:12.760
<v Speaker 3>better as our technologies develop. That are zero logic tests,

0:38:12.840 --> 0:38:17.200
<v Speaker 3>so looking just in your blood for antibodies against TTG,

0:38:17.360 --> 0:38:22.399
<v Speaker 3>so specifically ttgiga, and those are antibodies that you make

0:38:22.480 --> 0:38:25.560
<v Speaker 3>primarily in your mucosa, So these are the antibodies that

0:38:25.600 --> 0:38:29.839
<v Speaker 3>your guts are making against this TTG enzyme. And then

0:38:29.880 --> 0:38:32.600
<v Speaker 3>there are few other types of enzymes that we can

0:38:32.640 --> 0:38:36.879
<v Speaker 3>test for antibodies against as well. None of these are

0:38:36.960 --> 0:38:41.040
<v Speaker 3>one hundred percent perfect in diagnosis, and a lot of

0:38:41.080 --> 0:38:44.200
<v Speaker 3>times they rely on thresholds of like how high the

0:38:44.239 --> 0:38:47.560
<v Speaker 3>tighter is of these antibodies to be able to make

0:38:47.680 --> 0:38:52.799
<v Speaker 3>a definitive diagnosis. One of the challenges with all of

0:38:52.840 --> 0:38:56.840
<v Speaker 3>the types of testing that we have for diagnosis, including biopsy,

0:38:58.080 --> 0:39:01.480
<v Speaker 3>is that if someone is already adherent to a gluten

0:39:01.480 --> 0:39:08.120
<v Speaker 3>free diet, you can't diagnose coeliac disease because you're going

0:39:08.160 --> 0:39:11.239
<v Speaker 3>to have healing of the damage and a reduction in

0:39:11.280 --> 0:39:16.439
<v Speaker 3>these TDG antibodies, So a negative test doesn't rule out

0:39:16.480 --> 0:39:19.239
<v Speaker 3>coeliac disease. If someone is already on a gluten free diet,

0:39:19.280 --> 0:39:22.279
<v Speaker 3>they actually have to be exposed to gluten for these

0:39:22.320 --> 0:39:24.239
<v Speaker 3>tests to be accurate, if that makes sense.

0:39:24.760 --> 0:39:29.520
<v Speaker 1>Mm hmm, okay, question kind of follow up question.

0:39:29.920 --> 0:39:31.440
<v Speaker 3>Yeah, if you.

0:39:31.520 --> 0:39:34.960
<v Speaker 1>Are someone who has coeliac disease, and let's say that

0:39:35.080 --> 0:39:37.239
<v Speaker 1>it's what took a long time to get diagnosed and

0:39:37.239 --> 0:39:40.520
<v Speaker 1>there's been a lot of damage to your small intestine,

0:39:40.840 --> 0:39:44.839
<v Speaker 1>how much damage can there be before healing it? You know,

0:39:44.880 --> 0:39:47.080
<v Speaker 1>you can't get back to sort of what things were

0:39:47.160 --> 0:39:48.320
<v Speaker 1>before the damage began.

0:39:48.880 --> 0:39:51.480
<v Speaker 3>Yeah, it's a really good question. I don't have a

0:39:51.680 --> 0:39:57.160
<v Speaker 3>number on like how long someone how likely someone is

0:39:57.200 --> 0:40:00.000
<v Speaker 3>to have healing based on how long they had symptoms.

0:40:00.160 --> 0:40:03.160
<v Speaker 3>I don't have that data. But it is true that

0:40:03.200 --> 0:40:07.280
<v Speaker 3>about forty percent of people don't have complete mucosal healing.

0:40:09.040 --> 0:40:12.640
<v Speaker 3>So right now, in terms of treatment, the only treatment

0:40:12.640 --> 0:40:16.080
<v Speaker 3>that we have is a gluten free diet. The majority

0:40:16.120 --> 0:40:19.360
<v Speaker 3>of people, and some studies say like up to ninety

0:40:19.400 --> 0:40:22.399
<v Speaker 3>five percent some studies say even higher than that, will

0:40:22.440 --> 0:40:26.560
<v Speaker 3>have a complete or near complete resolution of their symptoms

0:40:27.080 --> 0:40:30.000
<v Speaker 3>of coeliac as a result of a very strict gluten

0:40:30.000 --> 0:40:33.640
<v Speaker 3>free diet. But only about forty percent of people have

0:40:33.800 --> 0:40:36.520
<v Speaker 3>complete healing of their mucosa. When you go back and

0:40:36.560 --> 0:40:41.040
<v Speaker 3>do another biopsy. What are the characteristics that are going

0:40:41.080 --> 0:40:43.280
<v Speaker 3>to determine that. I don't know. It's a really good question,

0:40:44.560 --> 0:40:47.799
<v Speaker 3>but it's something important because a lack of complete healing

0:40:47.880 --> 0:40:51.239
<v Speaker 3>like this continued inflammation in your small intestine can put

0:40:51.239 --> 0:40:54.880
<v Speaker 3>people with celiac disease at risk for certain cancers, especially

0:40:55.040 --> 0:40:58.320
<v Speaker 3>like lymphomas T cell lymphomas, because it is your T

0:40:58.480 --> 0:41:00.600
<v Speaker 3>cells that are primarily being activated it as part of

0:41:00.640 --> 0:41:03.920
<v Speaker 3>this immune process. But it can also put people at

0:41:04.000 --> 0:41:07.640
<v Speaker 3>higher risk of things like osteoporosis and hip fractures over time,

0:41:07.840 --> 0:41:14.840
<v Speaker 3>even if they are very adherent to that gluten free diet. Okay, yeah, yeah,

0:41:15.120 --> 0:41:19.200
<v Speaker 3>so that I mean that is coeliac disease in a nutshell.

0:41:19.719 --> 0:41:23.040
<v Speaker 1>If that's coeliac disease in a nutshell, then can you

0:41:23.120 --> 0:41:26.880
<v Speaker 1>tell me just briefly about the difference between coeliac disease,

0:41:27.400 --> 0:41:31.480
<v Speaker 1>non celiac gluten intolerance or non celiac gluten sensitivity and

0:41:31.600 --> 0:41:32.520
<v Speaker 1>wheat allergies.

0:41:32.880 --> 0:41:36.680
<v Speaker 3>Yes, I would love to, because I think it's really

0:41:36.719 --> 0:41:40.040
<v Speaker 3>important to recognize that, like, there are different entities aside

0:41:40.040 --> 0:41:43.239
<v Speaker 3>from coeliac disease. We know a lot about coeliac. We

0:41:43.400 --> 0:41:45.920
<v Speaker 3>know that it's autoimmune. We have markers that we can

0:41:45.960 --> 0:41:48.919
<v Speaker 3>test for it, and we know that gluten free diet

0:41:49.080 --> 0:41:53.360
<v Speaker 3>can be very beneficial and therefore is the standard of treatment.

0:41:53.760 --> 0:41:57.040
<v Speaker 3>Lifelong exclusion of gluten from the diet is treatment for

0:41:57.280 --> 0:42:01.640
<v Speaker 3>coeliac disease specifically. There are at least two other entities

0:42:01.640 --> 0:42:04.640
<v Speaker 3>that I think, in like common parlance, get conflated with

0:42:04.719 --> 0:42:09.120
<v Speaker 3>celiac disease, and that is wheat allergy, which is something

0:42:09.160 --> 0:42:13.480
<v Speaker 3>totally separate, and non seliac gluten sensitivity, which is kind

0:42:13.480 --> 0:42:15.680
<v Speaker 3>of a nebulous term that I'll talk a little bit about.

0:42:16.680 --> 0:42:21.319
<v Speaker 3>Wheat allergies are an allergy, and I cannot wait to

0:42:21.360 --> 0:42:27.080
<v Speaker 3>do allergies on this podcast. But allergies are IgE mediated,

0:42:27.120 --> 0:42:32.279
<v Speaker 3>so these are antibody mediated responses to an environmental exposure.

0:42:33.040 --> 0:42:38.480
<v Speaker 3>They are not autoimmune disorders, so there's no formation of

0:42:38.560 --> 0:42:42.960
<v Speaker 3>antibodies that are attacking yourself in an allergy. There's the

0:42:43.080 --> 0:42:47.600
<v Speaker 3>rapid onset and release of antibodies that are pre formed

0:42:47.760 --> 0:42:53.360
<v Speaker 3>against the environmental exposure. In this case, specific and separate

0:42:53.960 --> 0:42:59.400
<v Speaker 3>gliodin proteins that are present in wheat that trigger an

0:42:59.640 --> 0:43:04.680
<v Speaker 3>over active hypersensitivity response. So that is like a totally

0:43:04.760 --> 0:43:08.480
<v Speaker 3>separate thing. And like specific to gliadin proteins that are

0:43:08.480 --> 0:43:10.760
<v Speaker 3>present in wheat. And there's a lot of really interesting

0:43:10.800 --> 0:43:14.359
<v Speaker 3>things about allergies, especially like that are different as it

0:43:14.400 --> 0:43:18.880
<v Speaker 3>relates to coeliac disease, like exposure when you're young, and

0:43:18.960 --> 0:43:22.200
<v Speaker 3>the development of disease for allergies versus coeliac disease that

0:43:22.239 --> 0:43:25.560
<v Speaker 3>I think highlight that allergies are separate from autoimmune diseases,

0:43:25.640 --> 0:43:26.359
<v Speaker 3>if that makes sense.

0:43:26.600 --> 0:43:27.279
<v Speaker 1>Uhh, yes.

0:43:28.840 --> 0:43:32.800
<v Speaker 3>And then there is non celiac gluten sensitivity. This is

0:43:32.840 --> 0:43:35.840
<v Speaker 3>a disorder that I think is still relatively controversial in

0:43:35.880 --> 0:43:38.640
<v Speaker 3>some of the literature, but is recognized as a disorder

0:43:39.040 --> 0:43:42.880
<v Speaker 3>that often presents as kind of irritable bowel like symptoms.

0:43:43.040 --> 0:43:46.799
<v Speaker 3>An irritable bowel again, we should cover it someday. It

0:43:46.880 --> 0:43:49.920
<v Speaker 3>is something that is very nebulous. This could be diarrhea,

0:43:50.080 --> 0:43:53.600
<v Speaker 3>This could be constipation, This could be cramping, like really

0:43:53.640 --> 0:43:58.080
<v Speaker 3>bad cramping, abdominal pain. And sometimes with noncoliac gluten sensitivity,

0:43:58.080 --> 0:44:02.640
<v Speaker 3>we can see other non specific intestinal symptoms that tend

0:44:02.680 --> 0:44:06.200
<v Speaker 3>to start hours to days after eating food with wheat

0:44:06.360 --> 0:44:10.120
<v Speaker 3>or gluten or like from rye or barley, and tend

0:44:10.160 --> 0:44:13.000
<v Speaker 3>to get better when gluten is eliminated from the diet.

0:44:13.920 --> 0:44:18.080
<v Speaker 3>But in nonciliac gluten sensitivity. In people who have this disorder,

0:44:18.440 --> 0:44:23.040
<v Speaker 3>there are no identifiable auto antibodies, and endoscoped does not

0:44:23.160 --> 0:44:26.600
<v Speaker 3>reveal damage to the small intestine, and so this is

0:44:26.640 --> 0:44:31.880
<v Speaker 3>considered something that we essentially don't have any markers for,

0:44:32.640 --> 0:44:36.960
<v Speaker 3>and so it's often grouped under the larger classification of

0:44:37.080 --> 0:44:43.239
<v Speaker 3>kind of functional bowel disorders that are very real in

0:44:43.320 --> 0:44:47.000
<v Speaker 3>terms of the symptoms that people are having and experiencing,

0:44:47.080 --> 0:44:51.160
<v Speaker 3>and sometimes people can identify, for example, gluten as a

0:44:51.200 --> 0:44:56.319
<v Speaker 3>trigger for them. Sometimes people also when nonciliac gluten sensitivity,

0:44:56.480 --> 0:44:59.560
<v Speaker 3>do better when they have what's called a low FODMAP diet.

0:44:59.600 --> 0:45:02.279
<v Speaker 3>And that's a whole beast that we don't have time

0:45:02.320 --> 0:45:06.319
<v Speaker 3>to get into. But I suspect that someday a lot

0:45:06.360 --> 0:45:08.920
<v Speaker 3>of these diagnoses that are now under these big umbrella

0:45:09.040 --> 0:45:12.600
<v Speaker 3>terms are going to be separated out into multiple different

0:45:12.800 --> 0:45:16.959
<v Speaker 3>syndromes that have different potential causes, if that makes sense.

0:45:17.239 --> 0:45:21.319
<v Speaker 1>Yeah, hopefully that makes it more manageable to understand, Like,

0:45:21.719 --> 0:45:24.600
<v Speaker 1>maybe it's one thing and then eliminating that one thing,

0:45:24.640 --> 0:45:26.480
<v Speaker 1>wouldn't that be right?

0:45:26.600 --> 0:45:29.200
<v Speaker 3>Well, if it's the one thing that sometimes it's Oh

0:45:29.200 --> 0:45:30.520
<v Speaker 3>my gosh, I have a lot of feelings about this

0:45:31.160 --> 0:45:33.960
<v Speaker 3>because a lot of it's probably microbiomemediated. And so then

0:45:34.000 --> 0:45:37.239
<v Speaker 3>if you have this dyspiosis like you could potentially get

0:45:37.320 --> 0:45:40.480
<v Speaker 3>better even without having to have life long elimination of

0:45:40.520 --> 0:45:41.240
<v Speaker 3>certain things.

0:45:41.719 --> 0:45:45.160
<v Speaker 1>Or is it chicken and egg exactly? Is the mutrobiome

0:45:45.600 --> 0:45:48.839
<v Speaker 1>composition because of the disorder or is it leading to

0:45:48.880 --> 0:45:49.440
<v Speaker 1>the disorder?

0:45:49.520 --> 0:45:53.440
<v Speaker 3>It's yeah, right, yeah, But so in any case, it

0:45:53.520 --> 0:45:55.360
<v Speaker 3>exists as an entity.

0:45:55.440 --> 0:45:56.000
<v Speaker 1>It is real.

0:45:56.120 --> 0:45:58.760
<v Speaker 3>People have real symptoms from it. And if somebody feels

0:45:58.840 --> 0:46:02.160
<v Speaker 3>better not eating eat or not eating gluten, then that's great.

0:46:02.760 --> 0:46:05.160
<v Speaker 3>That's not what we're talking about today today. We're talking

0:46:05.200 --> 0:46:08.759
<v Speaker 3>just about Celiac disease, right, So, Aaron.

0:46:09.040 --> 0:46:11.160
<v Speaker 1>Now are we talking about the history.

0:46:10.840 --> 0:46:13.239
<v Speaker 3>Of can we please? I'd love to know about it.

0:46:13.360 --> 0:46:15.799
<v Speaker 1>Yes, Let's take a quick break and then I'll get

0:46:15.800 --> 0:46:46.760
<v Speaker 1>into it. Aaron. Aaron, you just beautifully took us through

0:46:46.880 --> 0:46:49.600
<v Speaker 1>all that we know about the path of physiology and

0:46:49.640 --> 0:46:53.680
<v Speaker 1>the symptoms and the treatment for Celiac disease, which as

0:46:53.719 --> 0:46:57.239
<v Speaker 1>you mentioned, pretty much consists of having a gluten free

0:46:57.400 --> 0:47:01.640
<v Speaker 1>diet or as gluten free as possible. And also what

0:47:01.800 --> 0:47:05.799
<v Speaker 1>can happen when someone with Celiac disease eats gluten like

0:47:05.920 --> 0:47:10.560
<v Speaker 1>not good yep uh. Probably that's putting it mildly. And

0:47:10.960 --> 0:47:14.120
<v Speaker 1>while it can be incredibly challenging to find gluten free

0:47:14.120 --> 0:47:16.960
<v Speaker 1>options in some parts of the world or to ensure

0:47:17.000 --> 0:47:20.200
<v Speaker 1>that no trace of gluten is in your food, you know,

0:47:20.520 --> 0:47:23.279
<v Speaker 1>thinking about like having dinner at a friend's house and

0:47:23.440 --> 0:47:26.440
<v Speaker 1>maybe they don't know that soy sauce has gluten, which like,

0:47:26.480 --> 0:47:29.919
<v Speaker 1>there are so many things, so much have gluten. That's

0:47:30.000 --> 0:47:32.439
<v Speaker 1>like why does it? But like there are so many

0:47:32.840 --> 0:47:35.920
<v Speaker 1>kind of random things like rice crispies have gluten apparently,

0:47:36.600 --> 0:47:40.520
<v Speaker 1>huh how so apparently like the packaged rice crispies are

0:47:40.560 --> 0:47:45.680
<v Speaker 1>not gluten free because they have a malt flavoring. Wow,

0:47:46.000 --> 0:47:48.880
<v Speaker 1>so and so many things have malt in them. Like

0:47:48.960 --> 0:47:52.120
<v Speaker 1>it's there's just a lot that gluten free is not, like, oh,

0:47:52.120 --> 0:47:55.520
<v Speaker 1>don't eat bread and pasta. It's right, so much more

0:47:55.560 --> 0:47:59.400
<v Speaker 1>than that, yeah, but yeah, and then like you're traveling

0:47:59.520 --> 0:48:05.040
<v Speaker 1>all of these things. But in theory, depending on where

0:48:05.680 --> 0:48:10.279
<v Speaker 1>you live, many people with Celiac disease can get a

0:48:10.440 --> 0:48:14.239
<v Speaker 1>decent handle on their symptoms by avoiding gluten right and

0:48:14.280 --> 0:48:16.239
<v Speaker 1>I know that that can be really difficult, depending on

0:48:16.280 --> 0:48:18.640
<v Speaker 1>where you live, depending on you know, a lot of

0:48:18.680 --> 0:48:21.560
<v Speaker 1>the times it's difficult, it's more expensive to eat a

0:48:21.560 --> 0:48:25.200
<v Speaker 1>gluten free diet, all of these things. But as restrictive

0:48:25.239 --> 0:48:29.120
<v Speaker 1>and difficult as this diet can be, coeliac disease is

0:48:29.680 --> 0:48:34.319
<v Speaker 1>fairly unique, I would say among autoimmune diseases for this,

0:48:34.520 --> 0:48:38.640
<v Speaker 1>for having this relatively straightforward way to manage symptoms. It's like,

0:48:38.800 --> 0:48:42.400
<v Speaker 1>we know the problem, we pretty much know the mechanism,

0:48:42.640 --> 0:48:45.200
<v Speaker 1>we know what's making you sick, and we can do

0:48:45.239 --> 0:48:48.799
<v Speaker 1>something about it. And again, I know this is a

0:48:48.840 --> 0:48:51.080
<v Speaker 1>general rule. I know that there are exceptions and that

0:48:51.120 --> 0:48:53.800
<v Speaker 1>a gluten free diet is not a breeze. But having

0:48:53.880 --> 0:48:58.640
<v Speaker 1>this option, or even knowing that this option exists, is

0:48:58.920 --> 0:49:02.680
<v Speaker 1>actually pretty recent in the history of celiac disease.

0:49:03.120 --> 0:49:03.839
<v Speaker 3>Well, I can't wait.

0:49:04.120 --> 0:49:08.640
<v Speaker 1>And by recent, I mean the nineteen fifties. Wow, it

0:49:08.719 --> 0:49:11.799
<v Speaker 1>was only then that the link between a gluten free

0:49:11.840 --> 0:49:15.920
<v Speaker 1>diet and alleviation of coeliac disease symptoms was made Gluten

0:49:16.040 --> 0:49:17.520
<v Speaker 1>celiac nineteen fifties.

0:49:18.200 --> 0:49:22.160
<v Speaker 3>Aaron, I just have so many questions, like how.

0:49:23.239 --> 0:49:27.760
<v Speaker 1>How how okay? Well, we'll get there like down the line. Okay,

0:49:27.760 --> 0:49:31.080
<v Speaker 1>but first let's go back thousands and thousands of years,

0:49:31.760 --> 0:49:37.120
<v Speaker 1>because what the heck did people do before then? Coeliac

0:49:37.200 --> 0:49:43.120
<v Speaker 1>disease has been around for ever basically and in our genes. Yeah,

0:49:43.320 --> 0:49:45.840
<v Speaker 1>and I'll get into that a little bit more in

0:49:45.840 --> 0:49:49.600
<v Speaker 1>a minute. And although there has been some discussion of

0:49:49.719 --> 0:49:53.800
<v Speaker 1>rates of celiac disease increasing, and the evidence is mixed,

0:49:53.880 --> 0:49:56.239
<v Speaker 1>like the rise in prevalence could be attributed to better

0:49:56.280 --> 0:50:00.400
<v Speaker 1>diagnostics and general awareness, although there is some sig congestion

0:50:00.520 --> 0:50:04.600
<v Speaker 1>that the more recently developed wheat strains may contribute to

0:50:04.680 --> 0:50:09.279
<v Speaker 1>have like different types of gluten or more immunologically sensitive

0:50:09.600 --> 0:50:12.879
<v Speaker 1>or triggering types of more iminogenic yeah, immunogenic. Yeah, there

0:50:12.880 --> 0:50:16.799
<v Speaker 1>we go again. It's not clear. But in any case,

0:50:16.800 --> 0:50:20.200
<v Speaker 1>celiac disease is certainly not a modern disease, and it

0:50:20.239 --> 0:50:23.480
<v Speaker 1>has been present for thousands of years of human history

0:50:24.120 --> 0:50:28.520
<v Speaker 1>since grain farming began, because like, celiac disease probably didn't

0:50:28.560 --> 0:50:31.000
<v Speaker 1>begin before grain farming, because there would have been no

0:50:31.160 --> 0:50:31.920
<v Speaker 1>trigger for.

0:50:32.560 --> 0:50:34.520
<v Speaker 3>You just weren't exposed to gluten.

0:50:34.440 --> 0:50:38.120
<v Speaker 1>Exactly, Like the potential was there, but right, the symptoms

0:50:38.160 --> 0:50:41.839
<v Speaker 1>were not. So I ask again, what the heck, did

0:50:41.840 --> 0:50:45.040
<v Speaker 1>people with celiac disease do before nineteen fifty just I

0:50:45.080 --> 0:50:46.280
<v Speaker 1>mean suffer.

0:50:46.320 --> 0:50:48.920
<v Speaker 3>Just not eat anything. I mean I feel like, did

0:50:48.920 --> 0:50:51.759
<v Speaker 3>they figure out like some foods were making them feel

0:50:51.760 --> 0:50:54.720
<v Speaker 3>sicker than others without knowing what it was about those foods?

0:50:55.120 --> 0:51:00.200
<v Speaker 1>So it's really unclear. Yeah, and I kind of want

0:51:00.200 --> 0:51:04.520
<v Speaker 1>to get into that because possibly, but that doesn't really

0:51:04.520 --> 0:51:06.320
<v Speaker 1>seem to be the case from medical writings.

0:51:06.600 --> 0:51:07.280
<v Speaker 3>Oh okay.

0:51:07.920 --> 0:51:12.279
<v Speaker 1>Unmanaged coeliac disease can wreak havoc on your body, as

0:51:12.320 --> 0:51:15.839
<v Speaker 1>anyone with celiac disease can probably tell you. It can

0:51:15.960 --> 0:51:19.759
<v Speaker 1>lead to malnutrition or death in juveniles and adults. It

0:51:19.800 --> 0:51:24.000
<v Speaker 1>can lead to wasting, malnutrition, greater susceptibility to infections, and

0:51:24.120 --> 0:51:29.440
<v Speaker 1>direct reductions in fertility. This is a disease with potentially severe,

0:51:29.680 --> 0:51:34.560
<v Speaker 1>even fatal consequences if left unmanaged. And yet for thousands

0:51:34.560 --> 0:51:38.320
<v Speaker 1>of years, people didn't apparently know that it was gluten

0:51:38.480 --> 0:51:42.960
<v Speaker 1>that led to their symptoms, And therein lies a mystery,

0:51:43.040 --> 0:51:47.120
<v Speaker 1>an evolutionary paradox as I've seen it described. What do

0:51:47.160 --> 0:51:50.080
<v Speaker 1>I mean by that? Like, what's the paradox? The paradox

0:51:50.280 --> 0:51:54.200
<v Speaker 1>is that coeliac disease is common in populations that have

0:51:54.320 --> 0:51:58.560
<v Speaker 1>a long history, again talking thousands of years of farming

0:51:58.600 --> 0:52:03.640
<v Speaker 1>wheat and other grains containing gluten, like Ryan Barley. Given

0:52:03.680 --> 0:52:09.120
<v Speaker 1>the potentially severe outcomes of unmanaged coeliac disease malnutrition, reduced fertility,

0:52:09.160 --> 0:52:11.960
<v Speaker 1>even early death, and the fact that Celiac disease is

0:52:12.120 --> 0:52:15.759
<v Speaker 1>highly heritable, meaning that it runs in families, you might

0:52:15.840 --> 0:52:19.880
<v Speaker 1>expect that as grain farming began more prominent beginning around

0:52:19.920 --> 0:52:23.360
<v Speaker 1>ten to twelve thousand years ago, when the Neolithic Revolution began,

0:52:23.800 --> 0:52:26.759
<v Speaker 1>coeliac disease would become less prevalent, as people with the

0:52:26.800 --> 0:52:29.719
<v Speaker 1>disease in areas where grain was a large part of

0:52:29.719 --> 0:52:32.879
<v Speaker 1>the diet probably would have had fewer kids, They likely

0:52:32.920 --> 0:52:35.920
<v Speaker 1>would have died younger, had more malnutrition, which would have

0:52:35.920 --> 0:52:39.920
<v Speaker 1>made them more susceptible to infections, and since celiac is

0:52:39.920 --> 0:52:43.760
<v Speaker 1>to a large degree heritable, that would all mean fewer

0:52:43.800 --> 0:52:47.560
<v Speaker 1>opportunities for those HLA genes to be passed down.

0:52:48.840 --> 0:52:51.640
<v Speaker 3>Expect you would expect that this is something that would

0:52:51.640 --> 0:52:55.680
<v Speaker 3>have been selected against in those grain farming populations.

0:52:55.280 --> 0:53:00.840
<v Speaker 1>Exactly, But that's not what we see, Huh. To the paradox,

0:53:01.320 --> 0:53:03.799
<v Speaker 1>And what's interesting is that I guess we don't know

0:53:03.920 --> 0:53:07.200
<v Speaker 1>this for sure, because like, we don't have a rate

0:53:07.320 --> 0:53:11.399
<v Speaker 1>of Celiac disease over time, right, right, But I've seen

0:53:11.480 --> 0:53:15.280
<v Speaker 1>rates of like one to two percent of the population basically,

0:53:15.360 --> 0:53:19.360
<v Speaker 1>which is a huge number, is it. I mean, I

0:53:19.400 --> 0:53:24.600
<v Speaker 1>don't know, Like I'm not sure enough about the mathematics

0:53:24.640 --> 0:53:27.759
<v Speaker 1>of HLA genetics and stuff like that and rates of

0:53:27.840 --> 0:53:31.080
<v Speaker 1>mutation and like all of these different aspects of that.

0:53:31.680 --> 0:53:35.440
<v Speaker 1>But to me, it seems like a lot.

0:53:35.680 --> 0:53:36.120
<v Speaker 3>I don't know.

0:53:36.800 --> 0:53:41.200
<v Speaker 1>It's interesting, it's interesting, Yeah, So what's going on? Like,

0:53:41.239 --> 0:53:45.280
<v Speaker 1>what are some hypotheses? Could it be that Celiac disease

0:53:45.600 --> 0:53:49.520
<v Speaker 1>was not as bad historically? So some people have suggested

0:53:49.560 --> 0:53:53.880
<v Speaker 1>that modern gluten containing grains have more or different kinds

0:53:53.920 --> 0:53:56.560
<v Speaker 1>of gluten that trigger more of an inflammatory response like

0:53:56.560 --> 0:53:59.960
<v Speaker 1>I mentioned, or that we simply eat more gluten nowadays

0:54:00.160 --> 0:54:03.880
<v Speaker 1>and processed foods stuff like that. That makes sense, Yeah,

0:54:03.920 --> 0:54:06.000
<v Speaker 1>And I'm not sure if we know enough about ancient

0:54:06.040 --> 0:54:08.719
<v Speaker 1>grains to make that comparison, or even if there was

0:54:08.760 --> 0:54:10.640
<v Speaker 1>a difference, whether it would have been big enough to

0:54:10.680 --> 0:54:14.520
<v Speaker 1>have an effect. Maybe it's a contributing factor. But we

0:54:14.600 --> 0:54:18.280
<v Speaker 1>also know that people with Celiac disease in ancient times

0:54:18.360 --> 0:54:21.960
<v Speaker 1>did get very sick. So, for instance, we have this

0:54:22.080 --> 0:54:26.320
<v Speaker 1>quote from Aretaeus of Cappadocia from the second century CE.

0:54:26.920 --> 0:54:31.719
<v Speaker 1>This is the first known description of coeliac disease. Quote emaciated,

0:54:31.760 --> 0:54:36.080
<v Speaker 1>an atrophied, pale, feeble, and incapable of performing any of

0:54:36.120 --> 0:54:39.000
<v Speaker 1>his accustomed works. But if he attempts to walk, the

0:54:39.040 --> 0:54:42.120
<v Speaker 1>limbs fail. The veins and the temples are prominent for

0:54:42.239 --> 0:54:45.319
<v Speaker 1>owing to wasting. The temples are hollow, but also all

0:54:45.400 --> 0:54:48.839
<v Speaker 1>over the body the veins are enlarged. Not only does

0:54:48.880 --> 0:54:52.120
<v Speaker 1>the disease not digest properly, but it does not distribute

0:54:52.120 --> 0:54:57.040
<v Speaker 1>that portion which the digestion has commenced. It appears to me, therefore,

0:54:57.120 --> 0:54:59.960
<v Speaker 1>to be an affection not only of digestion, but also

0:55:00.120 --> 0:55:03.560
<v Speaker 1>of distribution. End quote. So he's like, you're not absorbing

0:55:03.600 --> 0:55:05.800
<v Speaker 1>any food and you're not getting nutrients. That's kind of

0:55:05.840 --> 0:55:10.480
<v Speaker 1>what I'm interpreting that is. So we've got that description,

0:55:10.600 --> 0:55:14.319
<v Speaker 1>and then we've also got possible archaeological evidence. So there's

0:55:14.320 --> 0:55:17.360
<v Speaker 1>a paper from twenty ten that describes the skeleton of

0:55:17.400 --> 0:55:20.960
<v Speaker 1>a woman who died aged eighteen to twenty and lived

0:55:21.040 --> 0:55:25.920
<v Speaker 1>around two thousand years ago in southwestern Tuscany. The economy

0:55:25.960 --> 0:55:29.040
<v Speaker 1>of the city where she lived was based on wheat

0:55:29.040 --> 0:55:31.760
<v Speaker 1>and olives, and she seemed to come from a wealthy

0:55:31.760 --> 0:55:34.600
<v Speaker 1>family given certain aspects of her tomb, like there was

0:55:34.640 --> 0:55:37.840
<v Speaker 1>like gold and stuff like that, and this suggested to

0:55:38.040 --> 0:55:40.200
<v Speaker 1>the authors, to the researchers that she would have had

0:55:40.200 --> 0:55:44.160
<v Speaker 1>a good amount of wheat in her diet. But despite

0:55:44.239 --> 0:55:48.759
<v Speaker 1>the evident wealth, she died of malnutrition and her skeleton

0:55:48.840 --> 0:55:53.080
<v Speaker 1>shows possible signs of Celiac disease like shortness, anemia, dental

0:55:53.160 --> 0:55:57.600
<v Speaker 1>enamel hypoplasia, osteoporosis, and a deformity of the hip. And

0:55:57.840 --> 0:56:01.399
<v Speaker 1>I'm not sure how conclusive the like, how vague those

0:56:01.440 --> 0:56:04.239
<v Speaker 1>symptoms are, or how many other things they could possibly be,

0:56:05.000 --> 0:56:10.200
<v Speaker 1>but the authors suggest Celiac is a strong possibility. Okay,

0:56:10.280 --> 0:56:12.600
<v Speaker 1>So that was a long winded way of saying that

0:56:12.680 --> 0:56:15.680
<v Speaker 1>it's probably not that coeliac disease was mild or historically,

0:56:15.800 --> 0:56:19.000
<v Speaker 1>or just that we eat more gluten these days. So

0:56:19.200 --> 0:56:24.120
<v Speaker 1>onto the next hypothesis. Does having coeliac disease provide a

0:56:24.160 --> 0:56:27.040
<v Speaker 1>health trade off? So, for instance, does it give added

0:56:27.080 --> 0:56:31.759
<v Speaker 1>protection against certain infectious diseases? This has been suggested for

0:56:32.280 --> 0:56:36.360
<v Speaker 1>lots of autoimmune diseases like celiac. Essentially, the idea is

0:56:36.360 --> 0:56:40.080
<v Speaker 1>that our immune systems evolved under much different circumstances than

0:56:40.160 --> 0:56:43.799
<v Speaker 1>most of the world faces today, Where infectious diseases were

0:56:43.840 --> 0:56:48.640
<v Speaker 1>a constant threat and oftentimes a killer. Thanks to vaccines

0:56:48.680 --> 0:56:51.560
<v Speaker 1>and antibiotics and public health, it's not so much the

0:56:51.600 --> 0:56:56.160
<v Speaker 1>case these days, and as a result, without that persistent threat,

0:56:56.200 --> 0:57:01.960
<v Speaker 1>our immune systems have become overreactive like hygiene highypothesis fi Yes, right,

0:57:02.680 --> 0:57:05.480
<v Speaker 1>or a more specific example would be something like sickle

0:57:05.520 --> 0:57:09.440
<v Speaker 1>cell disease and malaria. So is it possible that celiac

0:57:09.520 --> 0:57:13.839
<v Speaker 1>disease stuck around despite gluten because it helped fight off

0:57:13.880 --> 0:57:17.360
<v Speaker 1>a more pressing threat like infectious disease, which was becoming

0:57:17.400 --> 0:57:21.320
<v Speaker 1>in general more common during the Neolithic Revolution as population

0:57:21.520 --> 0:57:30.560
<v Speaker 1>size and density increased. Perhaps we don't fully know classic

0:57:30.960 --> 0:57:34.240
<v Speaker 1>classic There isn't a whole lot of direct evidence that

0:57:34.280 --> 0:57:37.800
<v Speaker 1>people with Celiac disease are more resistant to certain infections,

0:57:38.080 --> 0:57:41.080
<v Speaker 1>but there does seem to be some association where the

0:57:41.200 --> 0:57:44.800
<v Speaker 1>genes or alleles linked to celiac disease, like those MLA

0:57:45.000 --> 0:57:48.800
<v Speaker 1>ones that you mentioned, are also involved in inflammation and

0:57:48.960 --> 0:57:53.040
<v Speaker 1>general immune function. Yeah again, I know that's super vague,

0:57:53.480 --> 0:57:56.360
<v Speaker 1>but it's hard to draw firm conclusions from these types

0:57:56.400 --> 0:57:59.440
<v Speaker 1>of studies. And remember, we are dealing with a decently

0:57:59.480 --> 0:58:05.080
<v Speaker 1>complex disease involving multiple genes or even networks of genes. Yeah. Yeah,

0:58:05.520 --> 0:58:09.240
<v Speaker 1>we know a good amount about the underlying genetics of

0:58:10.160 --> 0:58:13.840
<v Speaker 1>Celiac disease, but we don't have the complete picture, especially

0:58:13.880 --> 0:58:17.160
<v Speaker 1>when it comes to environmental factors, right, And like I.

0:58:18.160 --> 0:58:20.360
<v Speaker 3>Shout out HLADQ two and d Q eight, but there

0:58:20.360 --> 0:58:22.760
<v Speaker 3>are other genes that have been associated two that are

0:58:23.720 --> 0:58:24.720
<v Speaker 3>it's a whole mess.

0:58:24.840 --> 0:58:27.440
<v Speaker 1>It's a whole yeah, yeah, yeah. And so that brings

0:58:27.440 --> 0:58:30.600
<v Speaker 1>me to the third hypothesis, which is that Celiac disease

0:58:30.760 --> 0:58:34.120
<v Speaker 1>is kind of a side effect of evolution. As one

0:58:34.120 --> 0:58:37.640
<v Speaker 1>paper put it, essentially, since there are multiple genetic risk

0:58:37.680 --> 0:58:41.320
<v Speaker 1>factors for Celiac disease, each one of those factors on

0:58:41.440 --> 0:58:44.520
<v Speaker 1>its own might not be harmful, might not lead to

0:58:44.720 --> 0:58:48.439
<v Speaker 1>symptoms of Celiac disease, And in fact, each of those

0:58:48.520 --> 0:58:52.240
<v Speaker 1>on their own might be beneficial in immune function or

0:58:52.480 --> 0:58:55.680
<v Speaker 1>something like that, And so it stuck around, it was

0:58:55.720 --> 0:58:59.040
<v Speaker 1>selected for, it was maintained, and that could have been

0:58:59.040 --> 0:59:02.920
<v Speaker 1>what happened for different parts of the Celiac disease like

0:59:03.040 --> 0:59:06.800
<v Speaker 1>genetic risk network. So those factors helpful on their own,

0:59:06.840 --> 0:59:09.040
<v Speaker 1>so they stuck around, or maybe they were just kind

0:59:09.040 --> 0:59:11.680
<v Speaker 1>of they're not helping, like not good enough to keep around,

0:59:11.720 --> 0:59:14.840
<v Speaker 1>but not bad enough to like, you know, be selected against.

0:59:14.920 --> 0:59:18.280
<v Speaker 1>I guess, not helping, not harming neutral in any case,

0:59:18.480 --> 0:59:21.480
<v Speaker 1>because of the way that Celiac disease is caused by

0:59:21.520 --> 0:59:25.520
<v Speaker 1>this network of genetic risk factors, that means that Celiac

0:59:25.640 --> 0:59:28.800
<v Speaker 1>disease as a whole may not have been selected for

0:59:29.280 --> 0:59:32.520
<v Speaker 1>or against, but instead that evolution may have acted on

0:59:32.560 --> 0:59:35.680
<v Speaker 1>the individual parts. Right, hence the idea that it's a

0:59:35.680 --> 0:59:38.160
<v Speaker 1>side effect of evolution. Does that make sense?

0:59:38.360 --> 0:59:41.280
<v Speaker 3>I feel like that totally makes sense, especially because like, yes,

0:59:41.320 --> 0:59:44.240
<v Speaker 3>coeliac disease is highly heritable, but it's also not like

0:59:44.520 --> 0:59:47.000
<v Speaker 3>most of the genetic disorders that we've covered on this podcast.

0:59:47.080 --> 0:59:50.439
<v Speaker 3>It's not like it's not directly heritable like one to one,

0:59:50.640 --> 0:59:53.760
<v Speaker 3>and like like I mentioned, like twenty to thirty percent

0:59:53.760 --> 0:59:58.040
<v Speaker 3>of people have one or both of these various HLA types,

0:59:58.560 --> 1:00:01.520
<v Speaker 3>and the vast majority of them, something like fifteen or

1:00:01.560 --> 1:00:05.000
<v Speaker 3>so percent of people with high risk capitalotypes are in

1:00:05.040 --> 1:00:07.920
<v Speaker 3>studies go on to develop Celiac disease, Like, that's not

1:00:08.320 --> 1:00:13.560
<v Speaker 3>that high compared to everyone who has that h those haplotypes.

1:00:13.600 --> 1:00:15.400
<v Speaker 3>So it's it's complicated.

1:00:15.560 --> 1:00:18.680
<v Speaker 1>It's complicated, And I think I want to throw out

1:00:18.960 --> 1:00:21.960
<v Speaker 1>another hypothesis, which, by the way, none of these are

1:00:22.000 --> 1:00:25.080
<v Speaker 1>mutually exclusive, right, Like it can be that today's gluten

1:00:25.120 --> 1:00:28.640
<v Speaker 1>causes more inflammation and some of the alleles associated with

1:00:28.680 --> 1:00:32.200
<v Speaker 1>Celiac disease do help improve immune function, and that evolution

1:00:32.320 --> 1:00:36.040
<v Speaker 1>has acted on the parts, not the whole, right more

1:00:36.160 --> 1:00:39.600
<v Speaker 1>or less. And the last hypothesis all throw out there

1:00:39.760 --> 1:00:43.360
<v Speaker 1>is that what if the environmental trigger the big question

1:00:43.440 --> 1:00:46.960
<v Speaker 1>mark remaining in Celiac divise if that has increased in

1:00:47.000 --> 1:00:50.800
<v Speaker 1>frequency all the time. I again, we don't have we

1:00:50.840 --> 1:00:54.400
<v Speaker 1>don't know enough about the rates of Celiac disease over millennia,

1:00:55.160 --> 1:00:58.000
<v Speaker 1>but that is something that I think is a possibility.

1:00:58.200 --> 1:01:02.240
<v Speaker 1>So yeah, hopefully that was still interesting enough that even

1:01:02.360 --> 1:01:05.000
<v Speaker 1>though meaning even though I don't know was the punchline.

1:01:05.080 --> 1:01:07.400
<v Speaker 3>But I'm sorry, Aaron, have you ever listened to one

1:01:07.400 --> 1:01:10.000
<v Speaker 3>of my biology sections, That's always the punchline.

1:01:11.680 --> 1:01:13.280
<v Speaker 1>It wouldn't be an episode without it.

1:01:13.640 --> 1:01:15.440
<v Speaker 3>No, So that was.

1:01:15.480 --> 1:01:18.360
<v Speaker 1>A much deeper dive into the evolution of Celiac disease

1:01:18.360 --> 1:01:21.080
<v Speaker 1>than I expected to do. But I just I just

1:01:21.080 --> 1:01:23.280
<v Speaker 1>think it's so fascinating, and I think it shows us

1:01:23.280 --> 1:01:25.800
<v Speaker 1>that as much as we want there to be neat

1:01:25.840 --> 1:01:28.800
<v Speaker 1>little stories about evolution that we can like tie up

1:01:28.840 --> 1:01:31.680
<v Speaker 1>with a bow, we don't always get that, which makes

1:01:31.720 --> 1:01:33.919
<v Speaker 1>it all the more interesting. Do you know what else

1:01:33.920 --> 1:01:34.720
<v Speaker 1>I find interesting?

1:01:35.320 --> 1:01:35.720
<v Speaker 3>Everything?

1:01:36.800 --> 1:01:40.400
<v Speaker 1>The fact, yes, the fact that it took until the

1:01:40.480 --> 1:01:43.800
<v Speaker 1>nineteen fifties for people to make the connection between gluten

1:01:43.880 --> 1:01:44.840
<v Speaker 1>and symptoms.

1:01:45.240 --> 1:01:46.560
<v Speaker 3>I have so many questions.

1:01:46.800 --> 1:01:51.200
<v Speaker 1>Yeah, okay, so, I mean there are factors, and some

1:01:51.280 --> 1:01:56.680
<v Speaker 1>people's symptoms persist despite a strict gluten free diet. Plus

1:01:56.720 --> 1:01:59.600
<v Speaker 1>gluten isn't everything, so some of these things might have

1:01:59.680 --> 1:02:03.080
<v Speaker 1>made it more difficult. But still, so let's get into

1:02:03.120 --> 1:02:08.120
<v Speaker 1>how that connection was eventually made. Between Areteus's description from

1:02:08.120 --> 1:02:12.320
<v Speaker 1>the second century CE or so, there was mostly silence

1:02:12.400 --> 1:02:16.520
<v Speaker 1>on the Celiac front for about seventeen hundred years. Wow, okay,

1:02:16.720 --> 1:02:19.520
<v Speaker 1>so there's always an asterisk for these types of things. Also,

1:02:19.600 --> 1:02:23.240
<v Speaker 1>I'm pedantic, so I had to self correct. Probably other

1:02:23.280 --> 1:02:27.040
<v Speaker 1>people wrote about it or recognized it, but their descriptions

1:02:27.160 --> 1:02:30.000
<v Speaker 1>maybe their descriptions were lost to obscurity, or maybe they

1:02:30.040 --> 1:02:33.400
<v Speaker 1>weren't precise or clear enough to gain traction, or it

1:02:33.480 --> 1:02:35.680
<v Speaker 1>was people who were not in a position to be

1:02:35.720 --> 1:02:38.440
<v Speaker 1>writing medical text that were noticing these links and just

1:02:38.560 --> 1:02:42.800
<v Speaker 1>managing it on their own right. It's possible, but anyway,

1:02:43.240 --> 1:02:47.680
<v Speaker 1>in terms of medical literature, entered doctor Samuel Jones Ghee

1:02:47.760 --> 1:02:49.840
<v Speaker 1>in October eighteen eighty.

1:02:49.560 --> 1:02:52.960
<v Speaker 3>Seven, eighteen eighty seven, oh, okay, eighteen eighty seven yep.

1:02:53.240 --> 1:02:57.600
<v Speaker 1>That month, Gee presented a lecture titled on the Celiac Affection,

1:02:58.040 --> 1:03:00.880
<v Speaker 1>a nod to Aretaeus, who also used the term coeliac

1:03:00.920 --> 1:03:07.200
<v Speaker 1>diathesis or coeliac flux, with coeliac meaning belly quote. There

1:03:07.280 --> 1:03:10.080
<v Speaker 1>is a kind of chronic indigestion which is met with

1:03:10.320 --> 1:03:13.720
<v Speaker 1>in persons of all ages, yet especially apt to affect

1:03:13.800 --> 1:03:17.240
<v Speaker 1>children between one and five years old. Signs of the

1:03:17.240 --> 1:03:21.160
<v Speaker 1>disease are yielded by the feces being loose, not formed,

1:03:21.200 --> 1:03:24.720
<v Speaker 1>but watery, more bulky than the food taken. Would seem

1:03:24.760 --> 1:03:31.160
<v Speaker 1>to account for pale in color as if devoid of bile, yeasty, frothy,

1:03:31.600 --> 1:03:36.680
<v Speaker 1>and appearance probably due to fermentation, stinking stench, often very great,

1:03:37.040 --> 1:03:42.640
<v Speaker 1>the food having undergone putrefaction rather than concoction end quote.

1:03:43.440 --> 1:03:45.120
<v Speaker 3>Is this why you asked me about the details of

1:03:45.160 --> 1:03:45.960
<v Speaker 3>the diarrhea? Iran?

1:03:46.200 --> 1:03:50.560
<v Speaker 1>I did? Indeed, Yeah, this is exactly why I was, like,

1:03:50.720 --> 1:03:53.920
<v Speaker 1>there's I mean, I just assume that diarrhea does not

1:03:54.000 --> 1:03:56.480
<v Speaker 1>come in one shape and size.

1:03:56.800 --> 1:03:59.320
<v Speaker 3>No, it comes in many. There's just not one that's

1:03:59.400 --> 1:04:02.439
<v Speaker 3>like that. That description was beautiful. I don't think it's

1:04:02.440 --> 1:04:05.320
<v Speaker 3>indicative of everyone with Celiac's experience.

1:04:07.280 --> 1:04:09.520
<v Speaker 1>I just think poop can tell us so much. And

1:04:09.560 --> 1:04:12.120
<v Speaker 1>so I was curious, let's see an episode on poop.

1:04:12.720 --> 1:04:14.200
<v Speaker 3>Okay, I don't know.

1:04:14.400 --> 1:04:19.040
<v Speaker 1>Well, okay, what is the history of poop? I don't know.

1:04:20.800 --> 1:04:22.440
<v Speaker 1>I'm sure there's some good nuggets.

1:04:22.760 --> 1:04:25.960
<v Speaker 3>No pun intended, Yeah, pun intended?

1:04:29.120 --> 1:04:34.120
<v Speaker 1>Okay, okay. Anyway, so that description is now still hailed

1:04:34.160 --> 1:04:36.640
<v Speaker 1>as like this was a very clear description of what

1:04:36.880 --> 1:04:41.360
<v Speaker 1>was probably celiac disease. Right, So he wasn't sure, Gee,

1:04:41.480 --> 1:04:44.400
<v Speaker 1>wasn't sure what caused the disease. Quote the causes of

1:04:44.400 --> 1:04:47.400
<v Speaker 1>the disease are obscure. Why out of a family of

1:04:47.840 --> 1:04:50.600
<v Speaker 1>children all brought up in much the same way, should

1:04:50.600 --> 1:04:55.200
<v Speaker 1>one alone suffer? Nor was he certain about its path

1:04:55.200 --> 1:04:59.480
<v Speaker 1>of physiology? Quote naked eye examination of dead bodies throws

1:04:59.560 --> 1:05:02.800
<v Speaker 1>no light upon the nature of the coeliac affection. Nothing

1:05:02.880 --> 1:05:05.919
<v Speaker 1>unnatural can be seen in the stomach, intestines, or other

1:05:05.960 --> 1:05:09.640
<v Speaker 1>digestive organs. Whether atrophy of the glandular crips of the

1:05:09.680 --> 1:05:13.760
<v Speaker 1>intestines be ever or always present, I cannot tell. End quote.

1:05:14.680 --> 1:05:17.880
<v Speaker 1>But he did have a suspicion. Quote. If the patient

1:05:17.960 --> 1:05:21.640
<v Speaker 1>can be cured at all, it must be by means

1:05:21.680 --> 1:05:26.800
<v Speaker 1>of diet. End quote. Gee suggested, among other things, a

1:05:26.880 --> 1:05:30.520
<v Speaker 1>diet consisting solely of muscles.

1:05:30.680 --> 1:05:33.800
<v Speaker 3>Sorry, muscles like the like the the bivalve.

1:05:33.400 --> 1:05:37.360
<v Speaker 1>Yes exactly like that. Okay, interesting, So that was just

1:05:37.400 --> 1:05:40.280
<v Speaker 1>like one of the diets that he discovered worked for

1:05:40.320 --> 1:05:45.960
<v Speaker 1>one person. Okay, three to four pints of donkey milk daily. Okay,

1:05:46.200 --> 1:05:49.720
<v Speaker 1>No vegetables or fruit whatsoever, except a tablespoon or two

1:05:49.720 --> 1:05:50.720
<v Speaker 1>of mashed potatoes.

1:05:51.720 --> 1:05:52.920
<v Speaker 3>Sorry, you're gonna get scurvy.

1:05:53.280 --> 1:05:58.560
<v Speaker 1>Yeah I know, Okay, meat, juices, and bread sliced super

1:05:58.640 --> 1:06:02.920
<v Speaker 1>duper thin and toast on both sides. So if you

1:06:02.960 --> 1:06:05.080
<v Speaker 1>slice it really thin and you toast on both sides,

1:06:05.360 --> 1:06:09.400
<v Speaker 1>you're good. Right, you're good. You're not not.

1:06:09.640 --> 1:06:12.520
<v Speaker 3>But no fruits and vegetables except mashed potatoes. Do you

1:06:12.560 --> 1:06:14.960
<v Speaker 3>have to put donkey milk in the mashed potatoes? No?

1:06:15.080 --> 1:06:18.120
<v Speaker 1>Idea about the mashed potato recipe was not in any

1:06:18.160 --> 1:06:20.120
<v Speaker 1>of the papers that I read. I did. There was

1:06:20.160 --> 1:06:22.520
<v Speaker 1>another paper from the fifties, I believe that did have

1:06:22.560 --> 1:06:27.080
<v Speaker 1>recipes in it. Just FYI love that I know. And

1:06:27.160 --> 1:06:30.000
<v Speaker 1>so he was right in the general sense of things,

1:06:30.040 --> 1:06:33.200
<v Speaker 1>but not the specific It was diet related, but not

1:06:33.920 --> 1:06:34.840
<v Speaker 1>muscles only.

1:06:35.120 --> 1:06:37.360
<v Speaker 3>Not muscles document vegetables.

1:06:37.560 --> 1:06:43.320
<v Speaker 1>Yeah. But Gee's observations caught on, and several other physicians

1:06:43.360 --> 1:06:46.560
<v Speaker 1>began reporting on the coeliac affection as it was called,

1:06:46.920 --> 1:06:50.320
<v Speaker 1>including doctor R. A. Gibbons, who wrote in eighteen eighty

1:06:50.400 --> 1:06:55.400
<v Speaker 1>nine quote, this causes a serious alteration of the digestive process.

1:06:55.600 --> 1:06:59.080
<v Speaker 1>The food is too readily decomposed, and the absorption into

1:06:59.160 --> 1:07:02.439
<v Speaker 1>the blood of dill serious elements produces the profound ill

1:07:02.480 --> 1:07:06.480
<v Speaker 1>health from which patients attacked by this disease suffer end quote.

1:07:07.120 --> 1:07:10.160
<v Speaker 1>Over the first couple decades into the twentieth century, people

1:07:10.200 --> 1:07:13.400
<v Speaker 1>continued to try to unravel the mystery of celiac disease

1:07:14.000 --> 1:07:17.240
<v Speaker 1>and got so close to solving the puzzle, but ended

1:07:17.280 --> 1:07:21.360
<v Speaker 1>up sad and frustrated like GF. Still, who was rightly

1:07:21.440 --> 1:07:25.000
<v Speaker 1>convinced that it was a digestive disease due to diet,

1:07:25.040 --> 1:07:29.360
<v Speaker 1>and even recognized that quote. Unfortunately, one form of starch

1:07:29.400 --> 1:07:33.200
<v Speaker 1>which seems particularly liable to aggravate the symptoms is bread

1:07:33.880 --> 1:07:38.240
<v Speaker 1>end quote, something that even Aretaeus hinted at nearly two

1:07:38.280 --> 1:07:43.080
<v Speaker 1>thousand years before, but did still try a bread free diet,

1:07:43.720 --> 1:07:44.920
<v Speaker 1>not that I could tell.

1:07:45.480 --> 1:07:48.720
<v Speaker 3>Huh yeah, oh man, it seems to me like bread

1:07:48.760 --> 1:07:51.080
<v Speaker 3>is doing it. But let's figure it out by looking

1:07:51.120 --> 1:07:51.640
<v Speaker 3>somewhere else.

1:07:52.120 --> 1:07:57.320
<v Speaker 1>Yeah, and so somebody else. Sidney Haas in nineteen twenty

1:07:57.360 --> 1:08:01.520
<v Speaker 1>four introduced a banana diet which seemed to help at least.

1:08:01.560 --> 1:08:04.840
<v Speaker 1>He claimed that the eight individuals who received the banana

1:08:04.880 --> 1:08:07.840
<v Speaker 1>diet were clinically cured and the two who did not

1:08:07.960 --> 1:08:09.919
<v Speaker 1>receive the banana diet died.

1:08:10.960 --> 1:08:12.240
<v Speaker 3>What's a banana diet? Please?

1:08:12.480 --> 1:08:15.640
<v Speaker 1>Oh okay, it wasn't bananas, only just four to eight

1:08:15.800 --> 1:08:16.439
<v Speaker 1>a day.

1:08:16.880 --> 1:08:18.200
<v Speaker 3>Eight bananas a day.

1:08:18.360 --> 1:08:18.720
<v Speaker 1>Mm hmm.

1:08:19.360 --> 1:08:20.240
<v Speaker 3>It's a lot of fiber.

1:08:21.080 --> 1:08:27.640
<v Speaker 1>It's a lot of fiber, sugar free, no bread, no crackers,

1:08:27.680 --> 1:08:31.879
<v Speaker 1>no cereals, no potatoes. And it included a daily castor

1:08:31.920 --> 1:08:34.280
<v Speaker 1>oil cleanse and colonic irrigation.

1:08:34.840 --> 1:08:38.719
<v Speaker 3>My God, Like, you're still right on so many things

1:08:38.760 --> 1:08:41.400
<v Speaker 3>and so wrong at the same time.

1:08:41.760 --> 1:08:45.520
<v Speaker 1>Those bananas are just sliding straight through your entire digestive

1:08:45.560 --> 1:08:48.680
<v Speaker 1>tract like castor oil cleans.

1:08:49.000 --> 1:08:51.600
<v Speaker 3>No, I mean, you'll be good on vitamin D, So

1:08:51.680 --> 1:08:52.919
<v Speaker 3>that was probably important.

1:08:52.920 --> 1:08:55.120
<v Speaker 1>Honestly, I feel like there's got to be at a

1:08:55.160 --> 1:08:57.599
<v Speaker 1>certain number of days of the banana diet, there's got

1:08:57.640 --> 1:09:00.519
<v Speaker 1>to be some sort of like over abundance, some sort

1:09:00.560 --> 1:09:03.560
<v Speaker 1>of toxicity that you're getting from too many batassium.

1:09:03.680 --> 1:09:04.160
<v Speaker 3>Yeah.

1:09:04.240 --> 1:09:08.080
<v Speaker 1>Yeah. Do you always think of potassium from honey, Honey,

1:09:08.080 --> 1:09:10.840
<v Speaker 1>I've shrunk the kids, honey, honey, ourselves.

1:09:10.400 --> 1:09:13.360
<v Speaker 3>Honey, we shrunk ourselves one thousand percent. The only reason

1:09:13.360 --> 1:09:16.320
<v Speaker 3>that I know the bananas a source of potassium.

1:09:16.200 --> 1:09:22.519
<v Speaker 1>We too. I always think of it. Okay. Anyway, So

1:09:22.560 --> 1:09:25.160
<v Speaker 1>there's a lot that we could unpack about that paper

1:09:25.240 --> 1:09:28.719
<v Speaker 1>in the banana diet. But putting that aside, people were

1:09:28.840 --> 1:09:32.880
<v Speaker 1>beginning to like circle around the connection between gluten and

1:09:32.920 --> 1:09:37.160
<v Speaker 1>coeliac disease. It's likely that somebody would have gotten there eventually,

1:09:37.880 --> 1:09:42.559
<v Speaker 1>but rather tragic circumstances ultimately provided the evidence that clearly

1:09:42.560 --> 1:09:45.840
<v Speaker 1>demonstrated this link. In the winter of nineteen forty four

1:09:45.880 --> 1:09:48.920
<v Speaker 1>to nineteen forty five, food shipments were blocked to the

1:09:48.920 --> 1:09:52.080
<v Speaker 1>western part of the Netherlands by German forces, leading to

1:09:52.120 --> 1:09:56.080
<v Speaker 1>a famine, affecting millions of people with ultimately around twenty

1:09:56.160 --> 1:10:00.479
<v Speaker 1>thousand deaths. Estimates vary. The availability of wheat and rye

1:10:00.680 --> 1:10:06.200
<v Speaker 1>dropped to near nonexistent during this time, and one Dutch pediatrician,

1:10:06.439 --> 1:10:10.839
<v Speaker 1>Willem Carl Dick, noticed that his patients with Celiac disease

1:10:11.040 --> 1:10:14.960
<v Speaker 1>actually improved during the famine when they did not have

1:10:15.000 --> 1:10:18.719
<v Speaker 1>access to wheat and rye, and then when Swedish plains

1:10:18.800 --> 1:10:22.400
<v Speaker 1>dropped bread into the Netherlands to help relieve this food shortage,

1:10:22.479 --> 1:10:26.960
<v Speaker 1>those same kids experienced a relapse and got worse. And

1:10:27.000 --> 1:10:29.479
<v Speaker 1>so Dick put two and two together and realized that

1:10:29.600 --> 1:10:32.200
<v Speaker 1>it might be wheat and rye and barley that was

1:10:32.240 --> 1:10:36.000
<v Speaker 1>causing the problem, and later showed that it was wheat

1:10:36.040 --> 1:10:40.360
<v Speaker 1>flour and not wheat starch, ultimately pointing towards gluten as

1:10:40.439 --> 1:10:45.479
<v Speaker 1>the causative factor. Yeah, but apparently so kind of when

1:10:45.520 --> 1:10:48.040
<v Speaker 1>we're talking about, like, well, how did people not realize this?

1:10:48.080 --> 1:10:53.200
<v Speaker 1>Maybe they decided on an individual level. Apparently years before

1:10:53.240 --> 1:10:58.320
<v Speaker 1>in nineteen thirty, Dick had a patient who's had coeliac

1:10:58.400 --> 1:11:02.679
<v Speaker 1>disease whose mother told him that when she removed bread

1:11:02.720 --> 1:11:06.080
<v Speaker 1>and biscuits from her kid's diet that they got better.

1:11:06.960 --> 1:11:09.400
<v Speaker 1>So I feel like probably.

1:11:08.960 --> 1:11:11.960
<v Speaker 3>A lot was like that interesting.

1:11:12.600 --> 1:11:15.600
<v Speaker 1>But in any case, once Dick had presented his observations

1:11:15.680 --> 1:11:17.799
<v Speaker 1>the use of a gluten free diet to treat people

1:11:17.840 --> 1:11:22.439
<v Speaker 1>with celiac disease, it took off tremendously, wow, because it

1:11:22.520 --> 1:11:25.720
<v Speaker 1>was so I mean, it's so effect like, it's so effective, right,

1:11:26.240 --> 1:11:28.240
<v Speaker 1>And all that was left to do is figure out

1:11:28.520 --> 1:11:32.240
<v Speaker 1>the mechanism, the diagnostic criteria, molecular tests, the heritability of

1:11:32.240 --> 1:11:36.400
<v Speaker 1>the disease, and so on, all the other parts, all

1:11:36.439 --> 1:11:40.120
<v Speaker 1>the other parts of the puzzle. Over the second half

1:11:40.160 --> 1:11:43.920
<v Speaker 1>of the twentieth century, many of those parts were found

1:11:44.040 --> 1:11:47.559
<v Speaker 1>or were put together by research teams all over the world.

1:11:47.840 --> 1:11:49.599
<v Speaker 1>And I'm not going to go into the nitty gritty

1:11:49.680 --> 1:11:53.000
<v Speaker 1>of the history of discovery of those but instead what

1:11:53.080 --> 1:11:55.200
<v Speaker 1>I want to do is wrap up this history section

1:11:56.000 --> 1:11:59.800
<v Speaker 1>and talk by talking very briefly about the gluten free

1:11:59.800 --> 1:12:04.400
<v Speaker 1>tree friend that really took off around twenty ten or so.

1:12:04.640 --> 1:12:08.240
<v Speaker 1>As with most health related things that make headlines or

1:12:08.280 --> 1:12:13.400
<v Speaker 1>become trendy. It's a mix of fact fiction and people

1:12:13.680 --> 1:12:16.920
<v Speaker 1>wanting to make money. We should honestly do a full

1:12:16.960 --> 1:12:19.880
<v Speaker 1>episode on the gluten free diet. It's not clear to

1:12:19.920 --> 1:12:23.800
<v Speaker 1>me what initially propelled this gluten free diet to the

1:12:23.840 --> 1:12:28.320
<v Speaker 1>wild popularity that it achieved. But around this time around

1:12:28.400 --> 1:12:30.880
<v Speaker 1>you know, twenty tens or so, is when non celiac

1:12:30.960 --> 1:12:34.960
<v Speaker 1>gluten sensitivity was finally recognized as a real thing by

1:12:35.120 --> 1:12:38.640
<v Speaker 1>much of the medical community. And following that, we're a

1:12:38.640 --> 1:12:41.840
<v Speaker 1>bunch of articles and books that perhaps took this and

1:12:41.920 --> 1:12:44.960
<v Speaker 1>ran with it a bit too much, overstating the extent

1:12:45.040 --> 1:12:47.439
<v Speaker 1>to which a gluten free diet could improve the health

1:12:47.479 --> 1:12:50.879
<v Speaker 1>of those who do not have a diagnosed gluten disease

1:12:51.080 --> 1:12:56.000
<v Speaker 1>or sensitivity, saying things like, you know, eliminating gluten will

1:12:56.000 --> 1:12:59.240
<v Speaker 1>make you live longer, it will improve your brain health,

1:12:59.320 --> 1:13:03.799
<v Speaker 1>it'll improve of your relationships, it'll you know, like everything right, everything,

1:13:04.040 --> 1:13:08.160
<v Speaker 1>And it's what we see with so many diet fads.

1:13:08.200 --> 1:13:11.360
<v Speaker 1>It's what we see with so much health trends, like

1:13:11.920 --> 1:13:12.840
<v Speaker 1>it's a constant.

1:13:13.360 --> 1:13:16.719
<v Speaker 3>It's a diet fad like every other diet fadal exactly,

1:13:16.720 --> 1:13:17.280
<v Speaker 3>that's what it is.

1:13:17.439 --> 1:13:21.479
<v Speaker 1>Exactly, and then there was kind of this backlash right

1:13:21.520 --> 1:13:25.120
<v Speaker 1>where people were like, oh, you know, your gluten doesn't

1:13:25.200 --> 1:13:28.560
<v Speaker 1>mean anything, blah blah blah, and that there were a

1:13:28.600 --> 1:13:31.599
<v Speaker 1>couple of fair points I think to the backlash against

1:13:31.640 --> 1:13:35.040
<v Speaker 1>the gluten free diet, but not not very many fair

1:13:35.080 --> 1:13:38.200
<v Speaker 1>points because first, so here are the fair points. First,

1:13:38.360 --> 1:13:40.679
<v Speaker 1>there have been studies that show that people who do

1:13:40.720 --> 1:13:46.360
<v Speaker 1>not have gluten intolerance or sensitivity can experience nutritional deficiencies

1:13:46.520 --> 1:13:50.240
<v Speaker 1>with this restricted diet, like it can actually impact your

1:13:50.280 --> 1:13:56.080
<v Speaker 1>health negatively if you do not have gluten sensitivities or intolerance.

1:13:57.040 --> 1:14:00.640
<v Speaker 1>And secondly, it has led to the spread of or

1:14:00.760 --> 1:14:06.200
<v Speaker 1>unsupported pseudoscientific claims about the link between gluten and overall health,

1:14:06.720 --> 1:14:10.960
<v Speaker 1>again for people without diagnosed gluten disorders. The spread of

1:14:10.960 --> 1:14:13.639
<v Speaker 1>those claims and sort of this like, oh, well, this

1:14:13.760 --> 1:14:16.439
<v Speaker 1>one trick. You know, doctors hate this one trick.

1:14:16.680 --> 1:14:19.920
<v Speaker 3>Lose ten fats in belly fat or whatever, ten pounds

1:14:20.000 --> 1:14:22.160
<v Speaker 3>this it's a banana diet all over it.

1:14:24.240 --> 1:14:30.000
<v Speaker 1>Yeah, exactly, And this is like again, fad diets in

1:14:30.040 --> 1:14:33.240
<v Speaker 1>general are horrible for this type of pseudoscience and the

1:14:33.240 --> 1:14:38.880
<v Speaker 1>spread of pseudoscience. However, however, the road to diagnosis for

1:14:39.120 --> 1:14:42.680
<v Speaker 1>a non celiac gluten sensitivity or celiac disease can be

1:14:42.720 --> 1:14:45.760
<v Speaker 1>a really long one, and so this diet provides a

1:14:45.800 --> 1:14:49.679
<v Speaker 1>way of managing potential symptoms or seeing if gluten might

1:14:49.760 --> 1:14:54.000
<v Speaker 1>be the issue part of the issue for you. Secondly,

1:14:54.080 --> 1:14:59.200
<v Speaker 1>a gluten free diet does bring about huge health improvements

1:14:59.280 --> 1:15:02.599
<v Speaker 1>for those who can't eat gluten necessary, like it is

1:15:02.640 --> 1:15:06.639
<v Speaker 1>absolutely necessary. And Thirdly, it has done a great deal

1:15:06.760 --> 1:15:10.640
<v Speaker 1>to raise awareness I think of gluten intolerance and sensitivity,

1:15:10.760 --> 1:15:13.679
<v Speaker 1>and it has led to increased availability of so many

1:15:13.760 --> 1:15:17.960
<v Speaker 1>more gluten free products which prior to twenty ten were

1:15:18.000 --> 1:15:21.040
<v Speaker 1>not nearly as numerous. And again with the caveat that

1:15:21.080 --> 1:15:23.920
<v Speaker 1>this is not globally, this is in certain regions of

1:15:23.960 --> 1:15:27.080
<v Speaker 1>the world. But I do think that that raising the

1:15:27.160 --> 1:15:29.720
<v Speaker 1>awareness and we still have a long way to go,

1:15:30.080 --> 1:15:32.479
<v Speaker 1>you know, just the fact that, like when I was

1:15:32.560 --> 1:15:35.400
<v Speaker 1>researching this, there are so many products that have gluten

1:15:35.439 --> 1:15:38.479
<v Speaker 1>that I'm like, but why does it have to have gluten?

1:15:39.920 --> 1:15:41.960
<v Speaker 3>Well, and I feel like that is so true. And

1:15:41.960 --> 1:15:43.840
<v Speaker 3>then on the flip side, there's so many products that

1:15:44.000 --> 1:15:46.439
<v Speaker 3>now have the label of gluten free that I'm like,

1:15:46.800 --> 1:15:49.760
<v Speaker 3>an orange never have gluten in it is that have

1:15:49.880 --> 1:15:51.559
<v Speaker 3>to be on the label because it just makes things

1:15:51.680 --> 1:15:52.640
<v Speaker 3>more confusing.

1:15:52.800 --> 1:15:55.640
<v Speaker 1>It makes things more confusing. It is, I mean a

1:15:55.640 --> 1:15:59.360
<v Speaker 1>lot of it is a marketing thing, which is really predictable,

1:15:59.479 --> 1:16:03.080
<v Speaker 1>but frusht trading, and so I think it's it's like

1:16:03.120 --> 1:16:04.479
<v Speaker 1>a little bit of a trade off. I mean, I

1:16:04.479 --> 1:16:09.120
<v Speaker 1>think it's probably net positive for people who have gluten

1:16:09.160 --> 1:16:14.600
<v Speaker 1>sensitivities or celiac disease because it's like, oh, yes, gluten, Like,

1:16:15.000 --> 1:16:19.840
<v Speaker 1>did you know the word gluten before twenty agen. I'm

1:16:19.840 --> 1:16:20.760
<v Speaker 1>not proud that I did.

1:16:21.040 --> 1:16:22.320
<v Speaker 3>Yeah, unless you were a baker.

1:16:22.920 --> 1:16:27.120
<v Speaker 1>Yeah, exactly right, right. But yeah, maybe someday we should

1:16:27.120 --> 1:16:29.120
<v Speaker 1>do like a deep dive on just the gluten free

1:16:29.120 --> 1:16:31.559
<v Speaker 1>diet or other diet fads. But for now, I'm going

1:16:31.640 --> 1:16:33.760
<v Speaker 1>to turn it over to you, Aaron, to tell me

1:16:33.800 --> 1:16:35.840
<v Speaker 1>about celiac disease around the world today.

1:16:36.479 --> 1:17:04.519
<v Speaker 3>I can't wait to right after this break. So thank

1:17:04.600 --> 1:17:07.000
<v Speaker 3>you Erin for saying around the world today, because I

1:17:07.160 --> 1:17:10.640
<v Speaker 3>think that people don't maybe recognize that coeliac disease is

1:17:10.680 --> 1:17:15.280
<v Speaker 3>actually a global thing. It's everywhere. It is everywhere, I

1:17:15.320 --> 1:17:18.959
<v Speaker 3>think in part because of the kind of gluten free

1:17:19.000 --> 1:17:21.559
<v Speaker 3>trend or whatever you want to call it. That happened

1:17:21.680 --> 1:17:26.439
<v Speaker 3>in the twenty tens. Coeliac disease, which has in many

1:17:26.520 --> 1:17:29.720
<v Speaker 3>people's minds been conflated with other forms of gluten sensitivity,

1:17:30.280 --> 1:17:32.880
<v Speaker 3>has this perception that it's only a disease of like

1:17:32.960 --> 1:17:36.479
<v Speaker 3>the Western world or something, and that's not true at all.

1:17:37.760 --> 1:17:42.599
<v Speaker 3>The overall pooled global prevalence of coeliac disease is estimated

1:17:42.640 --> 1:17:46.799
<v Speaker 3>at around one point four percent. That's like most paper

1:17:46.920 --> 1:17:50.080
<v Speaker 3>site around that number. There's a little bit of variation,

1:17:50.880 --> 1:17:54.840
<v Speaker 3>and it's hopefully not surprising that there is estimated to

1:17:54.880 --> 1:18:00.679
<v Speaker 3>be some variation of this across the world. Prevalence is estimated,

1:18:00.920 --> 1:18:03.479
<v Speaker 3>surprising to me, to be a little bit higher in

1:18:03.560 --> 1:18:07.000
<v Speaker 3>Asia at about one point eight percent, and a little

1:18:07.040 --> 1:18:09.920
<v Speaker 3>bit lower to about the same as the global prevalence

1:18:10.240 --> 1:18:13.360
<v Speaker 3>in South America at one point three percent, and then

1:18:13.520 --> 1:18:15.600
<v Speaker 3>the European and North American prevalence, as far as I

1:18:15.600 --> 1:18:17.920
<v Speaker 3>can tell, is about equivalent to the global prevalence of

1:18:17.960 --> 1:18:22.000
<v Speaker 3>one point four percent. Okay, I also want to say,

1:18:22.320 --> 1:18:24.680
<v Speaker 3>and this is what's fascinating to me when I read this,

1:18:24.800 --> 1:18:30.519
<v Speaker 3>because I still don't quite understand how the first time,

1:18:30.600 --> 1:18:33.640
<v Speaker 3>and I think six seasons of making this podcast. The

1:18:33.680 --> 1:18:36.960
<v Speaker 3>main paper that I read for these epidemiology numbers said

1:18:36.960 --> 1:18:39.960
<v Speaker 3>that they thought that these numbers, this one point four percent,

1:18:40.520 --> 1:18:45.040
<v Speaker 3>could be an overestimate. What I know, right, I've never

1:18:45.080 --> 1:18:46.320
<v Speaker 3>seen overestimate.

1:18:47.960 --> 1:18:49.920
<v Speaker 1>Yeah, okay, so then what does that mean about where

1:18:49.960 --> 1:18:51.080
<v Speaker 1>these numbers come from.

1:18:51.520 --> 1:18:54.719
<v Speaker 3>Yeah, so that's the thing, because here's the other truth

1:18:54.840 --> 1:18:58.679
<v Speaker 3>is that a large proportion of people with Celiac disease

1:18:58.760 --> 1:19:02.320
<v Speaker 3>are undiagnosed. So when you look at, for example, like

1:19:02.360 --> 1:19:08.280
<v Speaker 3>biopsy confirmed prevalence estimates, they're closer to like point seven percent.

1:19:08.640 --> 1:19:11.400
<v Speaker 3>So this one point four percent is like a projection

1:19:11.720 --> 1:19:15.280
<v Speaker 3>estimate based on all of these different studies. But because

1:19:15.360 --> 1:19:18.759
<v Speaker 3>zero logic testing is imperfect and differs from place to place,

1:19:19.520 --> 1:19:21.880
<v Speaker 3>this paper at least said that it might be an overestimate.

1:19:21.960 --> 1:19:25.280
<v Speaker 3>So who knows. It's somewhere between point seven percent and

1:19:25.320 --> 1:19:30.360
<v Speaker 3>one point four percent globally fascinating. But one thing that

1:19:30.479 --> 1:19:33.519
<v Speaker 3>is consistent across all of the studies and in all

1:19:33.560 --> 1:19:37.920
<v Speaker 3>the geographic regions, and you mentioned this, aaron incidence does

1:19:37.960 --> 1:19:42.200
<v Speaker 3>seem to be increasing over time. This one paper from

1:19:42.240 --> 1:19:45.080
<v Speaker 3>just a couple of years ago estimated that the pooled

1:19:45.200 --> 1:19:49.960
<v Speaker 3>incidence worldwide is increasing like seven percent per year, So

1:19:50.040 --> 1:19:52.120
<v Speaker 3>that doesn't mean like seven percent globally, It just means

1:19:52.160 --> 1:19:55.640
<v Speaker 3>like compared to each year. And because celiac is a

1:19:55.680 --> 1:19:58.920
<v Speaker 3>chronic disease, there's no cure for it, an increase in

1:19:59.040 --> 1:20:01.760
<v Speaker 3>incidence necessary really means an increase in prevalence. So we

1:20:01.840 --> 1:20:04.680
<v Speaker 3>have new cases being diagnosed and therefore more people are

1:20:04.720 --> 1:20:09.680
<v Speaker 3>living with coeliac every year. Does that mean that the

1:20:09.880 --> 1:20:14.960
<v Speaker 3>true number of people who are developing celiac is increasing?

1:20:15.240 --> 1:20:18.160
<v Speaker 3>We don't know, because it could just be that we

1:20:18.200 --> 1:20:22.759
<v Speaker 3>are getting a lot better at diagnosing and recognizing coeliac disease.

1:20:23.479 --> 1:20:25.720
<v Speaker 3>But at this point we don't have enough data to

1:20:25.800 --> 1:20:31.360
<v Speaker 3>necessarily disentangle. Are the rates of disease truly going up

1:20:32.040 --> 1:20:34.479
<v Speaker 3>or are we just better at detecting it and so

1:20:34.520 --> 1:20:37.280
<v Speaker 3>we are seeing an increase in rates because of this

1:20:37.360 --> 1:20:43.400
<v Speaker 3>increase in detection wit or not. Yeah, But what is

1:20:43.400 --> 1:20:46.200
<v Speaker 3>still true today is that there is often a real

1:20:46.280 --> 1:20:50.040
<v Speaker 3>delay in diagnosis, and hopefully with better and better diagnostic

1:20:50.080 --> 1:20:52.920
<v Speaker 3>tools and more and more awareness, this delay kind of

1:20:52.960 --> 1:20:56.920
<v Speaker 3>decreases in time. I don't have perfect numbers on this,

1:20:57.040 --> 1:21:00.120
<v Speaker 3>but there was a survey in Finland that reported at

1:21:00.200 --> 1:21:03.400
<v Speaker 3>least a three year delay in diagnosis for about half

1:21:03.479 --> 1:21:07.839
<v Speaker 3>of people living with coeliac disease, and three years compared

1:21:07.840 --> 1:21:11.360
<v Speaker 3>to some other autoimmune disorders that we've talked about, might

1:21:11.400 --> 1:21:15.240
<v Speaker 3>not seem that long. What was endometriosis like ten years, twelve?

1:21:15.400 --> 1:21:18.280
<v Speaker 3>I think it's gone down in recent years. Yeah, Yeah,

1:21:18.880 --> 1:21:22.679
<v Speaker 3>But three years of not absorbing your nutrients, three years

1:21:22.680 --> 1:21:25.960
<v Speaker 3>of worsening anemia and osteoporosis like that, that's a very

1:21:26.000 --> 1:21:29.360
<v Speaker 3>long time, especially because a lot of people do develop

1:21:29.720 --> 1:21:33.280
<v Speaker 3>symptoms of coeliac disease when they are kids, like underage ten,

1:21:34.080 --> 1:21:37.240
<v Speaker 3>which means that you have kids that are not growing,

1:21:37.280 --> 1:21:39.759
<v Speaker 3>that are failing to thrive, and that are having delays

1:21:39.800 --> 1:21:43.679
<v Speaker 3>in their diagnosis. And adults too, because really a lot

1:21:43.720 --> 1:21:47.360
<v Speaker 3>of people don't develop symptoms of celiac until they're adults,

1:21:47.400 --> 1:21:50.160
<v Speaker 3>so it kind of is both ends of the spectrum,

1:21:50.840 --> 1:21:56.160
<v Speaker 3>which is really interesting. Yeah, in terms of the pathways

1:21:56.240 --> 1:22:00.120
<v Speaker 3>forward for coeliac disease, there of course is a lot

1:22:00.160 --> 1:22:03.760
<v Speaker 3>of research being done on what other factors might be

1:22:03.800 --> 1:22:06.759
<v Speaker 3>in terms of triggers and how we prevent celiac disease,

1:22:07.400 --> 1:22:09.840
<v Speaker 3>But one of the biggest areas of research is in

1:22:09.920 --> 1:22:14.679
<v Speaker 3>therapeutics and specifically in trying to find therapies that don't

1:22:14.880 --> 1:22:20.000
<v Speaker 3>require a strict gluten free diet, because while a gluten

1:22:20.040 --> 1:22:24.839
<v Speaker 3>free diet might be easier to achieve today or easier

1:22:24.840 --> 1:22:27.960
<v Speaker 3>for some people that for others, there's really nothing easy

1:22:28.160 --> 1:22:33.719
<v Speaker 3>about it. Like wheat is present globally in so much

1:22:34.160 --> 1:22:37.479
<v Speaker 3>even if you don't consider that, it's also hidden present

1:22:37.600 --> 1:22:40.280
<v Speaker 3>in so many of our standard American foods and in

1:22:40.360 --> 1:22:44.840
<v Speaker 3>packaged foods. Right, So not only is it expensive and

1:22:44.960 --> 1:22:47.839
<v Speaker 3>difficult to stick to it, but also can be socially

1:22:47.880 --> 1:22:51.599
<v Speaker 3>stigmatizing and like we heard in our first hand account,

1:22:51.680 --> 1:22:54.760
<v Speaker 3>it can lead to these unintentional difficulties in terms of

1:22:54.760 --> 1:22:59.880
<v Speaker 3>people's relationship with food, yes, and with Celiac disease especial,

1:23:00.600 --> 1:23:05.240
<v Speaker 3>even unintentional really small amounts of gluten can trigger severe

1:23:05.400 --> 1:23:10.400
<v Speaker 3>disease relapse. So there's a lot of interest, understandably in

1:23:10.400 --> 1:23:14.679
<v Speaker 3>developing other therapy options. As of today, twenty twenty four,

1:23:14.760 --> 1:23:18.120
<v Speaker 3>there's nothing that's like out there, there's nothing available, But

1:23:18.200 --> 1:23:20.479
<v Speaker 3>there are a few big buckets of research that I

1:23:20.479 --> 1:23:22.559
<v Speaker 3>wanted to just kind of highlight that people are looking

1:23:22.560 --> 1:23:26.519
<v Speaker 3>at in terms of different strategies. So one is what's

1:23:26.560 --> 1:23:30.920
<v Speaker 3>called like tolerance induction strategies, and so this is exposures

1:23:30.960 --> 1:23:34.320
<v Speaker 3>in various ways that try and trick the body into

1:23:34.360 --> 1:23:38.639
<v Speaker 3>developing essentially tolerance to gluten rather than having this really

1:23:38.680 --> 1:23:42.479
<v Speaker 3>strong reactivity. There's various types of exposures and exposure to

1:23:42.520 --> 1:23:45.000
<v Speaker 3>certain proteins and things like that that people are trying.

1:23:45.560 --> 1:23:48.719
<v Speaker 3>We don't have anything yet, but that's an idea. Another

1:23:48.800 --> 1:23:54.200
<v Speaker 3>idea is using gluten degradation think like LACTASEE for gluten. Yeah,

1:23:54.280 --> 1:23:58.040
<v Speaker 3>using these gluten aces, okay, so that people can break

1:23:58.040 --> 1:24:01.320
<v Speaker 3>down the gluten more efficiently to therefore expose it in

1:24:01.360 --> 1:24:03.559
<v Speaker 3>the same way to your T cells and not trigger

1:24:03.600 --> 1:24:08.960
<v Speaker 3>this inflammatory response. So that's another option. Another really interesting

1:24:09.000 --> 1:24:15.200
<v Speaker 3>idea is inhibiting that TTG, so inhibiting the tissue transglutaminase enzyme,

1:24:15.520 --> 1:24:18.840
<v Speaker 3>which then prevents the activation of those T cells and

1:24:18.880 --> 1:24:24.080
<v Speaker 3>reduces your inflammation because you're reducing the autoantibody formation essentially.

1:24:25.680 --> 1:24:30.280
<v Speaker 3>And finally, monoclonal antibodies, which more generally are targeting like

1:24:30.400 --> 1:24:35.240
<v Speaker 3>cytokine and inflammatory responses that coeliac triggers rather than like

1:24:35.479 --> 1:24:39.280
<v Speaker 3>specifics of coeliac or gluten itself. If that makes sense.

1:24:40.439 --> 1:24:43.360
<v Speaker 3>There's lots of different options out there. None of them

1:24:44.040 --> 1:24:48.080
<v Speaker 3>exist for humans today. There's a lot of them that

1:24:48.120 --> 1:24:50.719
<v Speaker 3>are in either preclinical or in some cases like phase

1:24:50.760 --> 1:24:53.680
<v Speaker 3>one and two clinical trials, So they're moving through the process.

1:24:54.280 --> 1:24:56.479
<v Speaker 3>And I think that in the future, like in the

1:24:56.479 --> 1:24:58.639
<v Speaker 3>next few years, we will likely see some of these

1:24:58.640 --> 1:25:00.719
<v Speaker 3>come to market and it'll be really interest to see

1:25:00.960 --> 1:25:02.800
<v Speaker 3>who gets access to them and how much they end

1:25:02.880 --> 1:25:07.800
<v Speaker 3>up helping people. Yeah, so that is coeliac disease today, Aaron.

1:25:08.320 --> 1:25:11.360
<v Speaker 1>It's amazing to me how on the surface it seems

1:25:11.520 --> 1:25:15.840
<v Speaker 1>very simple, very clear, very like, Okay, this is the thing,

1:25:15.960 --> 1:25:18.839
<v Speaker 1>this is the thing, But there's so much beneath the surface.

1:25:19.160 --> 1:25:22.600
<v Speaker 3>Oh, one hundred percent, one hundred percent always, it's always.

1:25:22.800 --> 1:25:25.880
<v Speaker 3>So if you'd like to learn a lot more, Dual boyd, we.

1:25:25.800 --> 1:25:28.960
<v Speaker 1>Have sources for Yeah, we do, indeed, Okay, I have

1:25:29.000 --> 1:25:31.920
<v Speaker 1>a lot. I'm going to shout out three. One for

1:25:31.960 --> 1:25:35.200
<v Speaker 1>the evolutionary history, one for the human history, and one

1:25:35.280 --> 1:25:37.519
<v Speaker 1>about sort of the gluten free diet. So the first

1:25:37.600 --> 1:25:41.320
<v Speaker 1>is by Sam and Hawks from twenty fourteen, titled Coeliac

1:25:41.400 --> 1:25:44.200
<v Speaker 1>Disease as a Model for the evolution of multifactorial disease

1:25:44.240 --> 1:25:48.479
<v Speaker 1>in Humans. Then for the history Pavely from nineteen eighty eight,

1:25:48.520 --> 1:25:52.360
<v Speaker 1>From Aretaeus to Crosby, A History of Celiac Disease, and

1:25:52.400 --> 1:25:55.280
<v Speaker 1>then about the gluten free diet by Newberry at All

1:25:55.320 --> 1:25:58.759
<v Speaker 1>from twenty seventeen, Going Gluten Free The History and Nutritional

1:25:58.800 --> 1:26:00.880
<v Speaker 1>Implications of Today's most popular diet.

1:26:01.479 --> 1:26:05.000
<v Speaker 3>Amazing. I have a few really interesting papers if you

1:26:05.080 --> 1:26:10.040
<v Speaker 3>want a deep dive on Celiac like Nitty Griddy. There

1:26:10.080 --> 1:26:12.400
<v Speaker 3>was a great paper from twenty twenty three titled the

1:26:12.400 --> 1:26:16.439
<v Speaker 3>Immunobiology and Pathogenesis of Celiac Disease by Iverson at All.

1:26:16.479 --> 1:26:20.840
<v Speaker 3>It was like such an incredible path of physiology deep dive.

1:26:21.600 --> 1:26:25.080
<v Speaker 3>I also use the American College of gastra Entrology most

1:26:25.080 --> 1:26:27.760
<v Speaker 3>recent guideline update, which was again from twenty twenty three

1:26:27.800 --> 1:26:30.920
<v Speaker 3>by Rubio Tapia at All. Several other papers by them.

1:26:31.400 --> 1:26:34.040
<v Speaker 3>Another paper by someone that I have worked with in

1:26:34.400 --> 1:26:37.000
<v Speaker 3>gastro andrology here in San Diego, which was really exciting

1:26:37.040 --> 1:26:39.479
<v Speaker 3>to see the fame of someone you know. They don't

1:26:39.520 --> 1:26:42.160
<v Speaker 3>know me, but anyways, that was Celiac disease from the

1:26:42.160 --> 1:26:45.439
<v Speaker 3>Annals of Internal Medicine from twenty twenty. We have so

1:26:45.560 --> 1:26:48.559
<v Speaker 3>many more papers from this episode and all of our

1:26:48.600 --> 1:26:51.280
<v Speaker 3>episodes on our website this podcast will Kill You dot

1:26:51.280 --> 1:26:53.280
<v Speaker 3>com under the episodes tab.

1:26:54.080 --> 1:26:57.880
<v Speaker 1>A huge thank you again to Beca for sharing your

1:26:57.880 --> 1:27:00.959
<v Speaker 1>story with us. We appreciate it so very much.

1:27:01.080 --> 1:27:04.040
<v Speaker 3>We really do. Thank you. Thank you also to Bloodmobile

1:27:04.120 --> 1:27:06.320
<v Speaker 3>for providing the music for this episode and all of

1:27:06.360 --> 1:27:07.080
<v Speaker 3>our episodes.

1:27:07.400 --> 1:27:10.280
<v Speaker 1>Thank you to Leana Squialacci and Tom Bryfogel for the

1:27:10.360 --> 1:27:11.559
<v Speaker 1>amazing audio mixing.

1:27:12.240 --> 1:27:14.880
<v Speaker 3>Thank you to everyone and Exactly Right Network.

1:27:14.800 --> 1:27:17.839
<v Speaker 1>And thank you to you listeners. Did you learn something?

1:27:17.920 --> 1:27:18.559
<v Speaker 1>We hope so?

1:27:18.760 --> 1:27:23.400
<v Speaker 3>I hope so I did. I did too, And as

1:27:23.439 --> 1:27:26.240
<v Speaker 3>always a special shout out to our patrons. Thank you

1:27:26.600 --> 1:27:29.800
<v Speaker 3>so much for your support. It really means the world

1:27:29.800 --> 1:27:30.160
<v Speaker 3>to us.

1:27:30.439 --> 1:27:34.880
<v Speaker 1>It does well. Until next time, wash your hands.

1:27:34.680 --> 1:27:35.679
<v Speaker 3>You feelthy animals

1:28:00.479 --> 1:28:00.719
<v Speaker 2>Foo