Gluten in Chinese Herbs

Addressing the Concerns of Those with Celiac Sprue

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND

Celiac sprue is a genetically based disease that causes allergic sensitivity to certain protein components that are rich in proline, called prolamins (or prolamines), and have a certain characteristic structure. The prolamins of wheat (gliadin), corn (zein), rye (secalin), barley (hordein), and oat (avenin) have varying potential for allergenic response, with that in corn and oats usually being low and that in wheat being especially high. These molecules are found in gluten, which is a major protein in processed wheat products, accounting for about 40% of the protein in the wheat strains commonly used in making bread and other baked goods. From the point of view of preparing these foods, gluten is a desired component, it is what makes the stringy, stretchy quality of dough, tapping air bubbles, and yielding the texture of the finished product.

For those with celiac sprue, an immune-based reaction to certain prolamins occurs in the small intestine which results in inflammation and damage to the intestinal villi. This damage then affects digestion because of the role of the villi in excreting digestive enzymes (the surface cells excrete sucrase, lactase, and maltase to digest complex sugars) and, especially, in absorbing food nutrients (the main role of the villi and the reason for the large surface area they present). Thus, two characteristics of celiac sprue are abdominal distress due to undigested and unabsorbed foods (especially foods with carbohydrates, like grains), and nutritional deficiency (with weight loss and other adverse consequences). Persistent exposure to gluten in those with celiac sprue can also result in disorders affecting other parts of the body, including the skin and heart. At this time, the only established remedy is to go on a gluten-free diet. This is a rather difficult task if a person doesn't prepare all meals for him or herself, because wheat is used in so many products (sometimes as a minor ingredient). In fact, going on a 100% gluten-free diet is nearly impossible, but considerable relief can be attained by eliminating virtually all gluten; single exposures to small amounts may produce an inflammatory response of the villi, but not the damage that occurs with repeated exposure.

Wheat is by far the gluten source with the largest presence in the food supply. Smaller amounts of gluten-like proteins are found in rye, barley, corn, and oats. Corn is thought to be safe for most people with celiac sprue and there is some debate (due to conflicting results of studies) over the situation with oats, as to whether its prolamins are acceptable, at least to some celiacs. For those attempting a gluten free diet, foods made with rye and barley must be avoided, and especially if they make up any significant part of a meal (thus, one can't replace wheat bread or breakfast cereal with a similar product made from these other grains).

Efforts have been made to determine the incidence rate of celiac sprue and the smallest amount of gluten that might be safe to consume. The extent of this genetic disorder in the population is a matter of concern because these grains are so widely distributed in the food supply: the issue is raised as to what extent is it necessary to accommodate the needs of those with celiac sprue (the extent becomes greater with higher frequency of celiac disease). New rules by the U.S. FDA are aimed at labeling foods that contain wheat (but not the other grains) and developing rules for what can be considered "gluten free." A related matter is the fact that diagnosis of celiac sprue has not been intensively pursued until recently (thus, some feel that the disease has not been given adequate attention). The slowness to diagnose the disease has come partly because it has a variable course over the lifetime (explained below) and partly because reliable testing has only been recently developed (symptom analysis alone is not reliable except in the more extreme cases).

The incidence of celiac sprue is greatest in Western Europe (where the genetic defect may have first been passed through the population) and in countries that derive a large part of their population from this region (e.g., U.S., Canada, Australia, New Zealand). By contrast the condition is rare in other populations, such as in Asians and Africans. It has been estimated that in Western Europe the incidence is about 0.33-0.40% of the population, and that in America it is about 1/10 that level. Those who believe that this condition is very much underreported (and there is no doubt that it has been underreported to some extent in the U.S.), suggest that the incidence might be as high as 0.5% for North America and Western Europe combined, and figures as high as 0.75% incidence for America have been projected.

There are other allergies that people may have to wheat or various grain proteins that would involve different reactions than found with celiac sprue. Food allergies from all sources combined are thought to affect as many as 6% of adults in America, and include reactions to proteins in fish, shellfish, peanuts, tree nuts, milk, and numerous other foods. These other food allergies typically do not cause damage to the intestinal villi. For example, several food allergies instead cause skin rashes or, in severe cases, anaphylaxis.

A part of the total celiac sprue disorder may be insufficient preliminary digestion of the grain proteins, since these proteins lose their allergenicity once broken down to individual amino acids or to very small peptides (less than about 15 amino acids in length). Protein digestion mainly takes place in the stomach. Although a genetic propensity to the disease is a necessary factor, weak protein digestion may make the condition more severe. Digestion promoting strategies, such as chewing food adequately, eating slowly, and ingesting digestive enzymes (especially those for protein), can help those with celiac sprue but do not eliminate the immune reactivity, so limiting gluten exposure is still necessary.

Also, the disease tends to have a variable course over the lifetime. It will usually first become evident in infants once grains are introduced into the diet, with digestive system disturbance and, in severe cases, slowing of growth. Then, as the body changes with maturation, the allergy will usually go into remission (perhaps having only a limited effect, so it is difficult to diagnose at that point). Finally with aging, the allergy will return, typically in the age range of 35-45. This is when many people are diagnosed.

Estimates of the safe level of gluten exposure for those with celiac sprue have been made. Part of the problem with using such estimates is that the severity of the disorder varies considerably among individuals (so some people may tolerate much larger amounts of gluten exposure while others may not tolerate even smaller amounts), as well as changes with age. For those whose condition is diagnosed relatively early, the gluten free or nearly gluten free diet allows for complete recovery; for those who have had the disease for decades and just now reduce their gluten intake, the extent of recovery of the intestinal lining may be limited.

A value that has been suggested as safe is exposure to about 30 mg/day. This is a tiny amount. With typical wheat flour having 40% gluten, 30 mg comes from less than 100 mg of wheat flour (a teaspoon full is about 3,000 mg, so 1/30th of a teaspoon). This amount would allow for inadvertent inclusion of something that contains traces of gluten in various meals. In determining an upper limit, it was found that daily exposure to 2.25 grams of wheat gluten (thus about 5.6 grams of wheat, around 2 teaspoons) in children with celiac sprue who had gained complete recovery after a gluten-free diet, yielded a return of symptoms after 1-15 months. The delay in generating symptoms, sometimes for over a year, suggests that 2.25 grams is close to the minimum value, so it is possible that 1 gram of gluten daily might be tolerated.

A problem with allergies is that they are not dose dependent in the manner that occurs with a toxic response; they can be triggered by small exposures in those who have the severe form of the disease. A percentage of the celiac sprue population may tolerate a greater amount of prolamins, but the quantity allowable even in those cases is still small, and may not permit, for example, eating a slice of bread (a thin slice of bread is about 20 grams, of which about 1 gram is gluten). The other grains (aside from wheat) have less prolamins, though the exact amounts depend on the grain variety, growing conditions, and processing into meal ingredients. Sensitivity to them may also vary.

CHINESE MEDICINAL MATERIALS

Wheat and barley (as well as other grains) are used in Chinese medicine, though not with high frequency other than in digestive formulas. The majority of Chinese herb formulas are free of grains. For those who are seeking to avoid any exposure to gluten, the wheat and barley ingredients would be entirely avoided, while for those who wish to simply keep exposure to a minimum, these substances might be used if the quantity can be limited (i.e., they represent a small fraction of the formulation). Only a few gluten-containing grains are used in Western practice of Chinese medicine, the three principal ones are outlined below.

Before describing the grain based Chinese herb materials, it should be noted that Western manufacturers of Chinese herbal products have been well aware of consumer concerns about use of potentially allergenic grains in the production of finished products, so that wheat, barley, corn, or other additives (such as soy) are not used in the manufacturing process. The potential source of gluten in these products is to be found in intentionally included grain-based herbal ingredients. As for products manufactured in Asia, while it is unlikely that grain proteins enter into the processing, there has been less concern about this matter, since Asians are virtually free of celiac sprue and grain allergies are not widely reported.

Wheat: Fuxiaomai (Triticum aestivum): This is the grain of one variety of wheat plant; although it is relatively low in gluten compared to grain used for making bread, it is still high enough to be of concern. This substance is primarily indicated for two uses: as a sedative and for nourishing the fluids to counteract "internal dryness." The lightest grains are selected by putting them in water and collecting the ones that float. The best known formulation including this ingredient is:

This is an ancient formula, recorded in the Jingui Yaolue (ca. 200 A.D.), and indicated for internal dryness marked by symptoms of emotional distress, irritability, sadness, easily crying, and insomnia, usually occurring with minor incidents or with no obvious cause. Generally, this condition is like that experienced by some women as they enter the menopause years, in which they notice that they become emotionally distressed when previously this had not been a significant problem Menopause is one example of a condition where there can be internal dryness (this is said to be the result of depletion of the kidney yin essence with aging). The formula is not restricted to use during menopause, there can be various conditions, some of them associated with feverish diseases, for which the formula is indicated, and many practitioners will prescribe it even when the condition of internal dryness is not evident, because it seems to have benefits for the mental agitation or depression generally. Fuxiaomai may also be used in formulas for treating spontaneous sweating and night sweats, but it is usually first processed by frying.

Malt: maiya (Hordeum vulgaris): This is sprouted barley, the malt used in making beer. It is primarily used to promote digestion, but also used to regulate the circulation of qi (prevents and resolves sensation of fullness and distention). This ingredient is included in several digestive formulations. A good example is:

The ingredients are powdered, made into pills, and given for the purpose of improving digestion and strengthening the digestive system; it is especially used when the symptoms of abdominal bloating and loose stool are present. The relatively large amount of chih-shih has the function of purging the gallbladder and digesting fats as well as dispersing the stagnation associated with abdominal bloating. Malt may also be used in treatment of disorders that involve swelling of the abdomen from causes other than indigestion, such as occurs when there is swelling of the liver (hepatitis) or spleen (from accumulation of blood cells). Another Chinese herb, coix (yiyiren) is sometimes called "pearl barley" but it is taxonomically distant from barley and the grains that are most problematic for those with celiac sprue; it is not believed to be allergenic.

Shen-chu (Shenqu): This is a fermented block of wheat or malt combined with various herbs, mainly herbs used to promote digestion. The fermentation process involves growing yeast on the grain substrate; this yeast is rich in digestive enzymes. Wheat was the traditional ingredient, but sprouted barley is increasingly relied upon; in either case, about 38% of the starting material is the grain. Shen-chu is mainly used as a digestive aid and is considered one of the best of those available in the Chinese Materia Medica; it can be used alone or in formulas. In many cases, it is combined with malt (the dried barley sprout, described above). For example, the formula Da Shanzha Wan is made with three ingredients: shen-chu, malt, and crataegus; it is used for poor appetite, weak digestion, and abdominal bloating (distention). The formula Jianpi Wan described above is often prepared by adding shen-chu during the process of making the pills. A widely used traditional formulation for food accumulating in the stomach without being digested well is:

These ingredients are ground to powder and then made into pills; they can be taken along with a decoction of the barley sprout (maiya) for better effect. This is for cases where the food is so stagnant that it leads to nausea, belching, possibly vomiting, and abdominal swelling. Adding malt into the pill as well will reinforce the action of the formula; the name of the prescription is then Shenqu Tang.

People who suffer from celiac sprue will often face digestive symptoms that are indications for use of malt and shen-chu. For those who have mild sensitivity to gluten, these formulations may relieve symptoms by aiding digestion without activating the celiac response because the amount of gluten present is small (exception: Da Shanzha Wan); for those who have strong sensitivity to gluten, formulas with these ingredients should be avoided. In the practice of Chinese medicine, the ingredients malt and shen-chu are considered very valuable for those with digestive weakness, so attention must be paid to the ingredients.

APPENDIX: ITM Formulary with Shen-Chu or Malt

The following items contain shen-chu or malt; the shen-chu used in current manufacturing is made with barley rather than wheat (which was used formerly):

Eclipta Tablets (Seven Forests): includes 6% malt
Shen-chu 16 (Seven Forests): includes 9% shen-chu
Stemona Tablets (Seven Forests): includes 10% shen-chu
Bupleurum-S (Seven Forests): includes 10% malt
Kang Ning Pian (Pine Mountain): includes 10% shen-chu
Bao He Wan (Pine Mountain): includes 12% shen-chu
Gallus-Malt Tablets (Seven Forests): includes 30% malt

December 2005