helminthic
what-are-helminths

what are helminths?

Helminthic therapy is the purposeful inoculation by ingesting intestinal worms in an effort to treat disease, and it has become increasingly popular in the treatment of autoimmune conditions. Is there evidence that helminthic therapy might work for gluten intolerance and celiac disease? Maybe. But while there has been an increase in the number of studies showing promise in the use of helminthic therapy for the treatment of autoimmune conditions, the evidence is still pretty loose and not entirely clinically appropriate.

Remember How Celiac Disease Works?
coeliac-disease

signs and symptoms of celiac disease

Celiac disease is an autoimmune condition where gluten consumption triggers the production of antibodies that attack the patient’s microvilli — these are the little, hair-like structures that line the small intestine. As digested food passes through the intestines, microvilli are meant to absorb nutrients, but with damaged or dysfunctional microvilli, celiac sufferers end up suffering from a variety of nutritional insufficiencies and deficiencies. To add insult to injury, the unabsorbed food moves to the large intestine and causes all sorts of gastrointestinal symptoms including gas, pain, bloating and diarrhoea. These symptoms can be mild but are often so severe that they significantly interfere with the person’s quality of life. In some cases, it can be debilitating. Celiac disease can also present with symptoms beyond the gastrointestinal tract — dermatitis herpetiformis (a rash), tingling in the limbs, ulcers in the mouth, and general signs of nutritional insufficiencies (muscle cramps, weight loss, mood issues). Currently, the only treatment for celiac disease is the elimination of gluten from the diet, and boosting nutritional status via the diet and supplementation to “fill up the tank” of nutrient supply, and remedy any deficiencies or insufficiencies. Remedying nutritional deficiencies can also help in the healing of the microvilli, which in turn makes it easier to absorb nutrients from food. Beyond that, not a lot can be done. Modern medicine doesn’t have any answers. The worst part for celiac sufferers is that avoiding gluten is a lot harder than you’d think — even a crumb of gluten can trigger an attack in some people and if you hadn’t noticed, our society is gluten-crazed. Good luck walking down the street and not bumping into a baked good! So anything that promises relief for celiac sufferers is newsworthy.



But is helminthic therapy legitimate?

A 2014 study conducted in Australia received attention for its assertion that inoculation with Necator americanus (commonly known as the human hookworm) may reduce the gastrointestinal symptoms in people with celiac disease when they eat gluten. While the gross-out factor may stop most people from purposefully infecting themselves with an intestinal parasite, there has been a long-held belief that parasites could aid in the maintenance and even in the restoration of health, particularly in the treatment of autoimmune disease. This type of treatment is called “helminthic therapy”. Helminthic refers to the type of parasites used — in layman’s terms, they are intestinal worms. The patient is inoculated with a small number of these worms in an effort to shift the immune system away from an autoimmune response to a normal, chilled out response. Apparently, it’s safe. So safe that the Medicines and Healthcare Regulatory Authority in the UK have allowed the use of hookworms for a treatment of autoimmune conditions! Keep in mind that they are only claiming it’s relatively safe — they’re not saying it’s effective.

But does it work? And how?

The theory behind the helminthic therapy is that the introduction of these particular parasites (or “inoculation”) causes a shift in the patient’s immune response. Let’s do a quick revision on immune dominance. If you recall, T-helper cells 1 (Th1) and T-helper cells 2 (Th2) are the first cells to initiate immune responses. The both do it in different ways and are active under different circumstances:

Diagram-Th0Th1Th2

Diagram-Th0Th1Th2

Th1

  • Cell-mediated immunity (cells attacking cells)
  • Responds to intracellular attackers (viruses, bacteria)
  • Causes inflammation
  • Overactivity = autoimmune conditions including celiac disease

Th2

  • Antibody-mediated (cells tell cells to create antibodies which then attack cells)
  • Responds to extracellular attackers (parasites)
  • Overactivity = allergies and some forms of asthma

In short, Th1 is dominant in autoimmune conditions such as celiac disease, and Th2 is activated when the body is invaded by or exposed to extracellular pathogens such as parasites. It’s as if these two sides of the immune system are on a see-saw — one goes up, the other goes down. It follows that introducing parasites should activate Th2, and therefore there should be a reduction in Th1 dominance. And since it is the over-activation of Th1 that is causing the destruction associated with celiac disease, the autoimmune process should reduce, and symptoms should abate, right? Maybe. Is the study legitimate? According to that 2014 study, the eight (8) participants who had celiac disease were able to eat up to 3g of gluten in wheat pasta after being infected with hookworms for 34 weeks. For a celiac sufferer, 3g of pasta would normally cause a serious flare-up of symptoms. Sounds good, right? The study had some serious shortcomings, which the authors themselves admitted to:

  1. Eight participants are way too few participants to apply any of the study’s findings to the wider population.
  2. The study had no control population, so it was impossible to compare the effects of the helminthic therapy to a group that wasn’t inoculated. This means that we don’t know if it was the hookworms that caused the improvement in symptoms, or if the participants were symptom-free after eating gluten due to some other unidentified factors.
  3. The study wasn’t blinded in any way — everyone participating knew exactly how much gluten they were eating and what the study designers were hoping to find. In epidemiology, it’s known that this kind of study design leads to reporting bias — on a conscious or subconscious level, the participants want to please the study designers, so they may have downplayed the severity of symptoms after eating gluten.

Even with these considerations, the study does, at the very least, show that helminthic therapy might have some merit and it should be studied further, with bigger populations of participants, and control settings. But putting together a study isn’t that easy — to publish a reliable, reputable paper, the study design has to be approved by an ethics committee before it goes ahead. An ethics committee needs to agree that everything about the experiment is reasonably safe for the participants. “I’m going to infect them with worms,” doesn’t sound particularly safe. But is it?

Safety of Helminthic Therapy for Celiac Disease

There are guidelines for the types of worms used in helminthic therapy according to Elliot, Summers & Weinstock: The helminth used must be shown that it:

  • Doesn’t multiply in the host
  • Has little or no potential to be pathogenic (i.e. cause damage)
  • Can’t be spread via contact with other people or animals
  • Self-limited colonisation in humans with no symptoms
  • Doesn’t affect the health of patients with suppressed immune systems
  • Commonly used medications don’t affect it
  • Can be easily eradicated with targeted medication
  • Doesn’t contain in itself any other pathogens
  • Can be produced in large numbers
  • Can be made stable for transportation and storage
  • Is easy to administer

Following these guidelines, hookworm is generally considered to be one of the safest helminths to use, and it is said to produce the fewest gastrointestinal side-effects. The gastrointestinal “side-effects” (aka symptoms) of hookworm are, ironically, similar to those of celiac disease:

  • Abdominal pain
  • Diarrhea
  • Loss of appetite
  • Weight loss
  • Fatigue
  • Anemia

And they also come with a whole lot of systemic symptoms too:

  • Progression of hookworms to the lungs can cause wheeze, cough and in severe cases, coughing up of blood.
  • Systemic effects of nutritional deficiencies

Many celiac patients may see it as a risk worth taking. Hey, I’m already getting those gastrointestinal symptoms, why not try? Listen… Let’s not lose sight of the facts. At the core of helminthic therapy for celiac disease is the fact that the hookworm is a parasite. This is not a symbiotic relationship. Parasites, by their very definition, feed at the expense of the host. They compete for nutrition. Celiac disease patients are notoriously under-nourished. The physical progression of celiac disease involves the destruction of the microvilli of the small intestine — this is where nutrients pass from digested food and into the blood. The extent of the damage done by the autoimmune processes may differ from patient to patient, but by the time celiac disease is diagnosed (often decades after its onset) it is likely there is a substantial strain on the patient’s nutritional status. The most common nutrient deficiencies in celiac disease patients differ depending on how long ago they were diagnosed and placed on a gluten-free diet:

Common Deficiencies in Recently Diagnosed Celiac Disease
gluten-free-foods

gluten free foods

  • Calcium
  • Magnesium
  • Zinc
  • Iron
  • Vitamin D
  • Vitamin B12
  • Vitamin B2 (riboflavin)
  • Vitamin B3 (niacin)
  • Folic acid (folate or B9)
  • Essential fatty acids (omega-3, omega-6, omega-9)
  • Fat soluble nutrients such as vitamin A, vitamin E, and vitamin K
Common Deficiencies in Celiac Patients on a Long-Term Gluten Free Diet
  • Fibre
  • Folate
  • Vitamin B12

So what does this have to do with hookworms in celiac disease?

How Hookworms Could Make Celiac Disease Worse
hookworms-life-cycle

hookworms-life-cycle

It may be argued that if the food is already in the digestive tract and not being absorbed by the damaged microvilli in the celiac patient, then it’s up for grabs! It’s just going to go to waste, right? Wrong. Hookworms are nourished by the host’s blood. That’s right, they’re tiny vampires. They hook onto the blood vessels in their host’s intestines and suck their blood for nutrients. It could be argued that in a celiac patient who already has a hard time getting nutrients into their blood, having those nutrients drained is not ideal. So what about that study from Australia? That seemed safe! No one died! Sure, there is a growing body of evidence that helminthic therapy may be effective in moderating the severity of autoimmune diseases in humans, including celiac disease. There are small studies showing that helminthic therapy may have promise in treating Chron’s disease, ulcerative colitis, and asthma. But these studies are done in laboratory conditions — that is to say, the participants are monitored very closely. That kind of monitoring isn’t practical in the real world, and that limits the scope of clinical application. It’s risky at best for a nutritionist, naturopath or doctor to administer a dose of helminths to a celiac patient without the kind of supervision that would be required to call it “safe”. That’d be more like constant monitoring at a hospital. It’s also considered unethical and could cost the practitioner their license depending on where they practice! Self-dosing is even riskier – without proper guidance of the professional, a progression of autoimmune dysfunction could easily result from nutritional deficiencies from celiac disease combined with the compounding factor of helminths draining precious nutrients. It could make the celiac disease worse, or lead to serious complications of hookworm infection like their infiltration into the lung we mentioned earlier! Talk about gross.

Conclusion on Helminthic Celiac Disease

While the theories behind helminthic therapy in celiac disease are interesting, the evidence is too limited to say that it’s safe or effective. This may be a sad truth for some celiac sufferers, but the one-shot cure isn’t here yet. It’s best to focus on eating a diet free from gluten and getting plenty of nutrients that promote immune balancing and repair of the intestinal microvilli. In particular, these nutrients can be of great benefit in celiac disease:

NUTRIENTS PURPOSE
Vitamin A Vitamin C Vitamin E Lycopene Quercetin Rutin These nutrients are potent antioxidants which will reduce inflammation. They’re also needed for epithelial cell turnover — that is, they help to repair the damage done by the autoimmune processes in celiac disease
Glutamine Helps to repair and maintain the intestinal barrier
Calcium Magnesium Iron Zinc These nutrients are commonly deficient in celiac patients and are therefore required in greater amounts and more frequently
Probiotics   Help to repair the intestinal barrier. They also improve the function of the enzymes on the microvilli to help in the absorption of nutrients, and they reduce inflammation in the gut.
Artichokes Inulin Bananas Asparagus Chicory Garlic These foods and nutrients are prebiotics — they are what the probiotics need to thrive!   CAUTION: Many celiac disease sufferers can have an intolerance to FODMAPS which many prebiotics are!
Helminthic Therapy in Gluten Intolerance
gluten-intolerance

gluten-intolerance

While hookworm infestation is proposed to reduce the symptoms of autoimmune conditions, there is no way that helminthic therapy could assist in the management of gluten intolerance, because gluten intolerance is not an autoimmune condition. The symptoms may be similar, but gluten intolerance is only diagnosed in the absence of any other gastrointestinal disease, including celiac disease. Usually, gluten intolerance is concluded when the symptoms flare up only from the consumption of gluten and a blood test shows no that there is celiac antibodies present. Think of it this way: gluten intolerance is not a celiac disease which is a gluten allergy. That said, there are limits to the celiac antibody blood test. Antibodies are produced in response to exposure to gluten, and they are responsible for the destruction of the microvilli of the small intestine. The amount of gluten that is required for the body to produce these antibodies differs between each celiac patient. A prolonged gluten-free diet will reduce these antibodies — that’s great news if you have a diagnosis of celiac disease, as removing gluten from your diet will certainly reduce gastrointestinal symptoms. But listen… If you have celiac disease but have already eliminated gluten from your diet before you go for the test, it’s possible that you won’t have produced these antibodies in great enough number for them to be present in the blood work results. In these cases, true diagnosis is only possible via endoscopy. Celiac disease is considered more serious than gluten intolerance as, in the latter, there is no histological damage — that is to say, the intestines aren’t actually damaged in gluten intolerance, and nutritional deficiencies are rare. Blood loss and anaemia are common in celiac disease but rare in gluten intolerance. Symptoms of celiac disease extend beyond the gastrointestinal system — a skin rash called dermatitis herpetiformis, tingling in the limbs, ulcers in the mouth, and general signs of nutritional insufficiencies (muscle cramps, weight loss). While gluten intolerance shares celiac’s gastrointestinal symptoms (bloating, pain, diarrhoea, gas), the patient won’t experience symptoms in the other body systems, and won’t experience symptoms once gluten has been eliminated from the diet. Celiac disease can take longer to recover from. Helminthic therapy might, possibly, have benefit in some people with some autoimmune conditions, possibly including celiac disease. But there is no reason why hookworm infection would reduce symptoms of true gluten intolerance. The only thing that will do that is getting gluten out of the diet!

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