To the Editor:
We at Cyrex would like to respond to the recent article by Dr Madiha Saeed, The Wheat Zoomer – Is It a Game Changer for Gluten Testing?
This response is not just in regard to the test mentioned in the article, but also to other similar gluten tests now on the market.
There is an interesting, paradoxical phenomenon in the healthcare industry. Health and wellness practitioners consistently advise their patients to use only high-quality, practitioner-only dietary supplement products, rather than purchasing cheaper counterparts from the local retail stores. The concept that “you get what you pay for” seems to be solid in the supplement market.
Yet, when it comes to laboratory testing, if a sales rep says, “we do more for less,” practitioners frequently leap at the cheaper price. Why is that?
All labs are not equal.
A few years ago, Cyrex went through an intensive vetting process conducted by the Institute for Functional Medicine (IFM). Dickran Boranian, MD, the IFM member assigned to interview Cyrex, was surprised by what he learned about the lab industry.
As part of the interview, we provided him with the quality control procedures performed by Cyrex--on each test, and each patient specimen. This goes far beyond the regulations set forth by the federal government. Dr. Boranian commented, “We doctors believe all labs are doing the same thing, so it doesn’t matter which lab we use; to us they’re all the same. Clearly, this isn’t true.”
Cyrex takes extra steps to make sure our test results are accurate. First, we use the purest starting antigens possible, optimize the proteins, and further optimize the proteins. Then, we conduct side by side duplicate testing. We are not required to do any of this; but 40 years of antibody testing in the hands of Dr. Ari Vojdani, a PhD immunologist who initiated food antibody testing in the US, has resulted in unparalleled know-how and effectiveness in this field on which Cyrex capitalizes for its unmatched, reproducible, and reliable processes.
Dr. Saeed briefly quoted Dr. Vojdani, who is considered by his peers to be 30 years ahead of the rest when it comes to laboratory test development, and holder of multiple US patents for laboratory tests. However, the weight of expertise in the article seems to have been given to a “Gluten Guru" who has no formal educational background in immunology or laboratory testing procedures and certification.
Cyrex: The Original
Cyrex Laboratories, LLC opened in January 2011. Our opening test menu included the Array 3 which assesses Wheat/Gluten Proteome Reactivity and Autoimmunity. This is the real ‘game-changer.’ Array 3, contains clinically relevant wheat proteins and peptides (both gluten and non-gluten), opioid peptides, multiple transglutaminases and the gliadin-transglutaminase complex. It was the first of its kind, and remains the finest in the industry.
This game-changing, patent-pending test panel, is based on years of research, as Dr. Vojdani strove to develop the most sensitive and clinically relevant assessment for wheat/gluten-reactivity.
But more doesn’t add clinical value.
Immunologically speaking, the additional wheat proteins offered in the Wheat Zoomer panel do not add value. In Dr. Vojdani’s published study, he found that no patient reacted to the additional wheat proteins, without already reacting to one or more of the antigens tested on Cyrex’s Array 3. The extra antigens make it look like the practitioner is getting more “information,” but unless there are clinical studies showing that these antigens have clinical value, this claim should not be made, particularly since clinical evidence exists to the contrary.
Array 3 is supported by peer-reviewed clinical publications.
Ever since Dr. Vojdani was introduced to the ELISA (Enzyme-Linked Immunosorbent Assay) testing technology in 1979, he has studied the nuances of the method, improved the procedures for greater sensitivity and specificity, and developed numerous ELISA-based tests, some of which are patented by the US Patent Office. Widely known as the "Father of Functional Immunology," Dr. Vojdani has published more than 150 peer-reviewed articles in this field.
One such patent covers Cyrex’s Array 2 – Intestinal Antigenic Permeability Screen, which includes occludin/zonulin antibodies.
What do Zonulin Levels Really Mean?
A few months before receiving this patent, Alessio Fasano’s patent on zonulin levels for assessing intestinal permeability was denied. The ELISA technology has been used in thousands of FDA sanctioned test kits. On the other hand microarray testing is still being improved. Researchers are currently publishing articles on ways to increase the sensitivity of the assay.[2-8]
From a clinical perspective, what do zonulin measurements really mean?
Sapone and colleagues published a study in which a small subset of autoimmune diabetes patients had elevated zonulin levels. Based on this article, many clinical laboratories added zonulin to their test menus. From an immunological point-of-view, zonulin level, by itself, has little clinical value.
HPC’s article on the Wheat Zoomer quotes Dr O’Bryan, “’…when the vast majority of the literature measures zonulin levels and not antibodies to zonulin, in my opinion the clinician is getting a more accurate evaluation when zonulin levels are included.’”
If one were to read the studies of zonulin levels, one would find that zonulin is in multiple barriers in the body, not just the intestinal barrier [10-14] Thus, researchers using zonulin for the assessment of ‘leaky’ lung or ‘leaky’ brain, combine that with other barrier-specific tests to ensure the zonulin being measured is coming from that specific barrier.
Furthermore, researchers have already shown that zonulin levels fluctuate in a matter of minutes to hours [9,15-16]. When measuring zonulin for clinical purposes, one would be required to do multiple blood draws several times throughout the day, over a period of days, to see if zonulin levels are consistently elevated. Elevations detected on a single measurement alone might simply reflect normal hour-to-hour fluctuations that occur in a natural rhythm.
As an immunologist looking for the best, most clinically-relevant tests, Dr. Vojdani studied the question of zonulin versus zonulin antibodies. His paper entitled “Fluctuation of zonulin levels in blood vs stability of antibodies” was recently published in the World Journal of Gastroenterology.
In this study, blood samples were drawn four times over two days. Both zonulin levels and zonulin antibodies were assessed in each blood draw. The zonulin levels fluctuated, bouncing between positive and negative, while the antibodies remained steady across the four blood draws.
All of this begs an important question: if zonulin levels show significant fluctuations for the same patient over a two-day period, how are “normal” reference ranges for zonulin established?
Ideally, practitioners order tests that provide accurate, reliable answers, which can guide them in making decisions that can truly help their patient. A better understanding of lab procedures, technologies and science can go a long way in determining what test is right.
HPC’s article rightly calls out the fact that, “Vibrant America declined to respond to the concerns raised by Dr. Vojdani, despite multiple requests for input.”
The Cyrex Team
- Vojdani A and Vojdani E. Gluten and non-gluten proteins of wheat as target antigens in autism, Crohn’s and celiac disease. J Cereal Sci, 2017; 75:252-260.
- Halper-Stromberg E, Frelin L, Ruczinski I, et al. Performance assessment of copy number microarray platforms using a spike-in experiment. Bioinformatics, 2011; 27(8):1052-1060.
- Evans SJ, Watson SJ, Akil H. Evaluation of sensitivity, performance and reproducibility of microarray technology in neuronal tissue. Integr Comp Biol, 2003; 43:780-785.
- Draghici S, Khatri P, Eklund AC, Szallasi Z. Reliability and reproducibility issues in DNA microarray measurements. Trends Genet, 2006; 22(2):101-109.
- Sabanayagam CR and Lakowicz JR. Increasing the sensitivity of DNA microarrays by metal-enhanced fluorescence using surface-bound silver nanoparticles. Nucleic Acids Res, 2007; 35(2):e13.
- Pawitan Y, Michiels S, Koscielny S, et al. False discovery rate, sensitivity and sample size for microarray studies. Bioinformatics, 2005; 21(13):3017-3024.
- Schwers S, Reifenberger E, Gehrmann M, et al. A high-sensitivity, medium-density, and target amplification-free planar waveguide microarray system for gene expression analysis of formalin-fixed and paraffin-embedded tissue. Clin Chem, 2009; 55(11):1995-2003.
- Jaksik R, Iwanaszko M, Rzeszowska-Wolny J and Kimmel M. Microarray experiments and factors which affect their reliability. Biol Direct, 2015; 10:46.
- Sapone A, de Magistris L, Pietzak M, et al. Zonulin upregulation is associated with increased gut permeability in subjects with type 1 diabetes and their relatives. Diabetes, 2006; 55:1443-1449.
- Romem A, Lammers K, Iacono AT, et al. Zonulin – a novel player in human lung pathophysiology. Am J Respir Crit Care Med, 2012; 185:A4266.
- Tripathi A, Lammers KM, Goldblum S, et al. Identification of human zonulin, a physiological modulator of tight junctions, as prehaptoglobin-2. PNAS, 2009; 106(39):16799-16804.
- Rittirsch D, Flierl MA, Nadeau BA, et al. Zonulin a prehaptoglobin2 regulates lung permeability and activates the complement system. Am J Physiol Lung Cell Mol Physiol, 2013; 304:L863-L872.
- Shimojima N, Eckman CB, McKinney M, et al. Altered expression of zonula occludens-2 precedes increased blood-brain barrier permeability in a murine model of fulminant hepatic failure. J Invest Surg, 2008; 21(3):101-108.
- Stamatovic SM, Keep RF, Andjelkovic AV. Brain endothelial cell-cell junctions: how to “open” the blood brain barrier. Current Neuropharrmacol, 2008; 6:179-192.
- Drago S, El Asmar R, Di Pierro M, et al. Gliadin, zonulin and gut permeability: effects on celiac and non-celiac intestinal mucosa and intestinal cell lines. Scan J Gastroentrol, 2006; 41:408-419.
- Sapone A and Fasano A. Serum zonulin and intestinal permeability before and after a gluten-containing meal in both Type 1 diabetes and in their relatives. T1D Anna Lab Meeting. 2005, http://archive.hshsl.umaryland.edu/handle/10713/2418
- Vojdani A, Vojdani E, Kharrazian D. Fluctuation of zonulin levels in blood vs stability of antibodies. World J Gastroenterol, 2017; 23(31):5669-5679.