The Neurobiology of Lipids in Autistic Spectrum Disorder

The biochemical complexity of Autistic Spectrum Disorder (ASD) has led us towards an in depth exploration of its systemic presentation from a cellular perspective. Previous examination of patients with ASD have revealed immune insult with an autoimmune presentation.^1-23 Through the efforts of Wakefield²⁴ at the Royal Free Hospital in London, gut biopsy and ongoing clinical trials have also suggested viral involvement of ASD with positive staining for measles in lymphoid follicles from measles vaccination. Wakefield has hypothesized that there may be a viral interaction between measles vaccination and exposure to chicken pox that initiates the immune derangement in ASD. Protocols for treatment of GI disturbance were limited until Borody²⁵ applied the work of Tvede and Rask-Madsen²⁶ with the oral application of bacterial strains such as non-toxigenic avirulent strain of Clostridium Difficile (sixteen strains of bacteria in all were utilized) with cessation of major symptoms in five children (to date) with autism.

Renowned microbiologist Dr. Sidney Feingold²⁷ has identified at least 12 genus of anaerobic bacterial species missing in four autistic children (hundreds of culture plates were run for this determination) in contrast to controls (forthcoming publication) after a lay facilitator, Ellen Bolte,²⁸ proposed the connection between tetanus vacination (clostridium tetani) and autism. The hypothesis forming in regard to autism and clostridium is that neurotoxins are being formed through the immune/gut/CNS axis creating the stereotypic behavior (actually hallucinogenic in nature) exhibited in autistic spectrum disorder. The use of potent antibiotics and therapeutic use of

probiotics has not adequately addressed ASD. Borody’s approach is to sterilize the gut with potent antibiotics and reimplant the proper balance of all bacteria (including those we consider to be pathogenic). Oral application of bacteria (rather than rectal implantation) may be utilized if the gut is sterilized and medicines (i.e Prilosec) are used to suppress acid formation. This may permit the bacteria to pass undisturbed through the GI tract. Efficacy of this therapy in the gut and brain have recently been observed.

The concept of opiatelike peptides affecting children with ASD was developed by Shattock,^29-30 Reichelt,^31-32 and others^33-34through examination of urinary metabolites containing peptides from gluten and casein. The opiate antagonist naltrex-one proved unsuccessful in controlled trials^35-39 with dietary removal of gluten and casein yielding anecdotal positive results. Association with ASD and serotonin was scrutinized in intricate detail^40-43 but not clarified until Matson⁴⁴ (1996, unpublished data) isolated bufotinines, methylated serotonin compounds, in the serum of children with ASD. Matson found that these compounds may be created by the patient evoking hallucinogenic symptoms, and found that children with ASD over-methylate. Friedman⁴⁵ (stated in public forum) noted analysis by tandem mass spectrophotometry that aberrant peptides originally derived from casein/gluten as well as Clostridium created hallucinogenic effects initially linking casein ingestion to cellular surface immune response, specifically CD26, which is crucial to clearing of beta-casomorphin. Friedman continued his research (study submitted for publication) linking the effect of opiates from gluten, casein, and particular species of Clostridium upon the suppression the enzyme Dipeptidyl Peptidase-DPP4 or CD26 ultimately impacting the liver, kidney, small intestine and blood brain barrier where this enzyme predominates.

The role of CD26 is primarily one of T cell activation, and the cleavage of peptides at the location of proline and alanine thereby breaking down aberrant peptides or inactivation of neuropeptides. Friedman has noted that the amino acid sequencing of peptides in the urine of children contain D-alanine and D-proline isomers, and CD26 cleavage of these isomers is 1000 fold greater than peptides containing the L-isomers of these amino acids. The research of Friedman and Matson link endogenous polypeptides to autistic behaviors (hallucinogenic in nature). Matson’s research is oriented to serum rather than urinary metabolites, and suggests that the endogenous creation of bufotinines may be related to bizarre behavioral patterns.

In designing therapeutic treatment strategies, clinicians must consider the following significance factors in the pathogensis of ASD: passage of peptides through the blood brain barrier; electrolyte instability; allergic manifestation; GI disturbance and intestinal permeability.⁴⁶ All these markers are indicative of a loss of cell membrane integrity. Bauman⁴⁷ and Minshew^48-49 have clearly identified aberrations in neurons and membrane phospholipids in ASD patients. Certainly the removal of casein and gluten may be of tremendous benefit, but metabolic entropy, immune dysregulation and loss of cell membrane integrity must be addressed to sustain the health of multiple body systems.

Information on the use of secretin for ASD has exploded in the press and parents have demanded this treatment, even in the absence of proper scientific investigation such as clinical trials. Understandably, the success of secretin therapy has been mixed, where secretin has evoked speech in some while in others the results have led to auto-immune responses and seizures. The metabolic effects of secretin are that it stimulates the arachidonic acid cascade (contraindicated in seizure disorders), and bicarbonate production. This state will burn off (beta oxidize) fatty acids (including both essential fats, insulating fatty acids and very long chain fatty acids), and increase the metabolism of bile acids. Secretin may also stimulate cholecystokinin-B (CCK-B), which plays a neuromodulatory role in GABA-ergic neurons which may be involved in speech production. Wilson⁵⁰ reports stimulation of speech at the time of administration of secretin with the use of provocative neutralization technique, therefore full doses or repeated infusions may be unnecessary. Infusions of secretin will correct the acidosis that most children with ASD present with ultimately impacting hyperammonemic (bicarbonate plus ammonia yields urea) states that may be stabilized with an increase in bicarbonate production. Perhaps one should consider oral repletion of bicarbonates as a less invasive intervention.

Each of the biochemical aberrations isolated in children with ASD demand that we examine the cell membrane integrity (including the blood brain barrier), membrane traffic (electrolyte stability and blood gases), the peptidelipid membrane, nitrogen retention, and the very essence of the communication in the body, the prostaglandins.

Children with ASD present with hepatic, gastrointestinal, renal, immune, endocrine and CNS disturbances which reflect striking metabolic derangement. This is most clearly revealed in examination of red cell lipids (representing four months of cellular metabolism), and show the accumulation of very long chain fatty acids (VLCFAs) indicative of suppressed peroxisomal beta oxidation.

Peroxisomes are organelles within cells which are pivotal in the biotransformation of endogenous compounds in lipid metabolism such as fatty acids, steroids, prostaglandins, the formation of myelin, neurotransmission, and detoxification of exogenous compounds and xenobiotics.^51-52The accumulation of VLCFAs inside the cell membrane represents defects in peroxisomal beta oxidation.⁵³This condition may be used to profile the deleterious effects characteristic of autistic spectrum disorder on the brain, endocrine, gastrointestinal and immune systems, and hepatic cytochrome P450 derangement (involving nitric oxide synthase) due to auto-immune⁵⁴ presentation. Therefore, the toxic aspect so often described in autism may be defined clearly through examination of RBC lipids with elevation of VLCFAs a reflection of blocked detoxification mechanisms.

Cellular Interactions and Treatment

Presently, physicians struggle to understand which antioxidants, detoxification methods, hormonal support or prooxidant therapies are appropriate in treating ASD. This dilemma can now be clarified through new understanding of cellular organelle interactions. Tremendous attention has been directed to the mitochondria (energy producing organelle) yet the most important organelle in regard to lipid metabolism and detoxification is the peroxisome.

Peroxisomes are present in virtually all cells but are most prevalent in the liver and kidney where they play a critical role of cellular lipid metabolism and biosynthesis of fatty acids (via beta oxidation). This process involves important physiological substrates for VLCFAs, dicarboxylic fatty acids, prostaglandins, thromboxanes, leukotrienes, pristanic acid, DHCA, THCA and xenobiotics. Individuals with immune, CNS and endocrine disorders often present with complex xenobiotics indicating disturbances in the cytochrome P450 superfamily, a state which parallels disturbances in peroxisomal function. The cytochrome P450s are responsible for the biotransformation of fatty acids, steroids, prostaglandins, leukotrienes and vitamins, as well as the detoxification of exogenous compounds. This process may result in substantial alterations of P450s as xenobiotics may turn off or greatly reduce the expression of constitutive isoenzymes.

Inappropriate use of antioxidants inhibit the beta oxidation or burning of cellular fatty acids and suppress normal lipid metabolism. Large doses of vitamin E, for example, will inhibit tumor shrinkage as beta oxidation is suppressed. Thus potent antioxidants are contraindicated in toxic states (i.e. in the buildup of VLCFAs). The administration of DHEA, pregnenolone, or thyroid hormone stimulates the beta-oxidation of VLCFAs as would pro-oxidant nutrients and oxidative therapies. Children with ASD most often present with acidosis,⁵⁴ low CO2/Bicarbonate⁵⁴ and low oxygen.^54,55 Stimulating beta oxidation, however, concurrently stimulates the burning off of essential fatty acids (EFAs), thus it is crucial that the delicate balance of controlling redox potential, beta oxidation, and the administration of essential substrates (lipids, proteins) and catalysts (vitamins, minerals) be utilized specific to the individual child with ASD.

There is now an large body of evidence that suggests that essential fatty acids play a fundamental role in the brain, cell to cell interactions and genetic expression. Understanding lipid and EFA metabolism is crucial for maintaining both physical and mental health. New research on targeted lipid manipulation has shown that dietary changes can dramatically influence the body, and most profoundly, the brain. ⁶²

Viewing the brain of the child with ASD as a biological orchestration as it relates and interacts with membrane lipids offers a new understanding of the specificity of disturbances within the brain in regard to lipids/peptide interactions on a cellular level and the intricate integration of essential fatty acids and prostaglandins.

Although the CNS cannot be controlled without attention paid to lipid substrates, fatty acid metabolism has been poorly understood and often is simply ignored in treatment protocols. Proper evaluation and attenuation of lipid metabolism in ASD can provide a powerful therapeutic tool that integrates the CNS, immune, endocrine, hepatic, renal, gastrointestinal, pulmonary and cardiovascular systems.

Red Cell Lipid Analyses Findings

Examination of over 700 red cell lipid analyses⁵⁴ of children with ASD have revealed the following characteristic patterns: elevation of VLCFAs (erucic, lignoceric, lumequic, behenic, adrenic, pentacosanoic acids); depression of myelination markers (as the DMA phospholipids); suppression of PG1 synthesis (ASD patients respond to clonidine and pentoxifilline due to stimulus to PG1,^56-59); elevation of the arachidonic acid cascade/PG2 synthesis;⁶⁰ and auto-immune derangement (with elevation of EPA/DHA characteristic of disturbances in cytochrome p450 enzymes, Nitric Oxide Synthase (NOS) and peroxisomal dysfunction.⁵⁴ NOS and Nitric oxide (NO) formation is augmented by supplementation of DHA in marine oils.

The autoimmune presentation of ASD may initially respond negatively to marine oils, DHA or flax oil due to both the competitive inhibition of omega 3s to omega 6s (PG1 series prostaglandins appear to be suppressed⁵⁴ in children with ASD) and the stimulation of NOS/NO towards the autoimmune process. Nitric oxide is the smallest biologic product of the human cell and is intimately involved in synaptic plasticity, immunity, neurotransmission, electrolytic stability, vascular regulation, neuromodulation, gastrointestinal and hepatic function. Imbalance of lipid substrates or inhibition of prostaglandin synthesis pathways due to immune insult may create complex immune-CNS interactions that are caused by disturbances within cell membrane dysfunction. Omega 6 essential fatty acids (in this case the precursor PG1 as evening primrose oil) must be repleted and stabilized before omega 3 supplementation commences.

Consider carefully that the synthesis of prostaglandins is an oxidative process, therefore loading with antioxidants or the incorrect sequence of EFA repletion may impede progress in ASD therapy. Complex nitrogen metabolism is apparent in children with seizures, developmental delay and ASD and involves not only Nitric Oxide, but nitrogen retention as a whole (first described by Mary Coleman⁶¹ as “purine autism”).

Patients presenting with suppression of CO2 may shun nitrogen (protein) rich foods which form ammonia (hyper-ammonemia). Although buffers and butyrates attenuate abnormal nitrogen metabolism, children with ASD are unique in their presentations. As we examine nitrogen retention/NO, electrolyte stability, catalysts, lipid status we see disturbances in metabolism which require that we use integrative therapies developed from a cellular perspective.

Conclusion

Previously, researchers studying autism were hindered by a lack of medical literature on the importance of essential fatty acids in health and the different physiological effects of their trans and cis isomers. This situation resulted in misinformation among practitioners in regard to appropriate protocols for lipid manipulation. Intractable disorders such as adrenoleukodystrophy (ALD) have brought clarification to the labyrinth of lipid pathways, as separate fatty acids are studied and manipulated through lipid (drug) therapy and other systemic interventions. Medicine has been slow to acknowledge the crucial lipid requirements (4 to 1 ratio of omega 6 to omega 3 or SR3 by Yehuda⁶²) to address neurological degeneration, and now that the data is emerging, it is difficult to extrapolate and utilize it towards successful therapeutic applications.

By studying the research data and isolating individual fatty acids in red cells we can now examine the intricate circuitry of the fatty acid derived prostaglandins, stabilize cell membrane integrity, and for the first time establish lipid treatment protocols with a greater understanding of the brain through red cell membrane dynamics. This may finally open a gateway into resolving autism and many of the neurodegenerative disorders of our time.

References

Warren RP, Burger RA, Odell D, et al: Decreased plasma concentrations of the C4B complement protein in autism. Arch Pediatr Adolesc Med, Feb 1994; 148:180-3.
Warren RP, Singh VK., Cole P, et al: Increased frequency of the null allele at the complement C4B locus in autism. Clin and Ex Immunol, 1991; 83: 438-440.

Warren RP, Singh VK. Cole P, et al: Possible association of the extended MHC haplotype B44-SC30-DR4 with autism. Immunogenetics , 1992;
36: 203-207

Warren RP, Cole P, Odell JD, et al: Detection of maternal antibodies in infantile autism J Am Acad Child Adolesc Psych, 1990; 29: 6:873-877,

Warren RP, Yonk LJ, Burger RA, et al: Deficiency of suppresser/ inducer (CD4+CD 45RA+) T cells in autism. Immun Invest, June, 1990; 19:3:245
251.

Warren RP, Yonk J, Burger RW, et al: Positive T cells in autism: association with decreased plasma levels of the complement C4B protein. Neuropsychobiol, 1995; 31:53-57
Warren RP, Odell JD, Warren WL, et al: Immunoglobulin A deficiency in a subset of autistic subjects. J Autism Dev Disord, 1997 Apr; 27(2):187-92.
Warren RP, Odell JD, Warren WL, et al: Association of the 3rd hypervariable region of HLA-Drß1 with autism. J Neuroimmunol, 1996 Jul; 67(2)97-102.
Warren RP, Singh VK: Elevated serotonin levels in autism: association with the major histo-compatibility complex. Neuropsychobiology, 1996; 34:72-75.

10. Daniels WW, Warren RP, Odell JD, et al: Increased frequency of the extended or ancestral haplotype B44-SC30-DR4 in autism. Neuropsychobiol, 1995; 32(3):120-3.

11.Yonk LJ, Warren RP, Burger RA, et al: CD4+ helper T cell depression in autism. Immunol Letters, Sept 199;: 25:4:341-346.

Singh VK, Warren RP, Odell JD, et al: Changes of soluble IL-2, IL-2 receptor, T8 antigen IL-1 in the serum of autistic children. Clin Immunology and Immunopathology, 1991; 61:448-455.
Singh VK, Warren RP, Odell JD, et al: Antibodies to myelin basic protein in children with autistic behavior. Brain Behavior Immun, 1993; 7:97-103.
Gillberg C: Endogenous opioids and opiate antagonists in autism: brief review of empirical findings and implications for clinicians. Dev Med Child Neurol, 1995; 37:239-245.
Gillberg C: Brief Report: onset at age 14 of a typical autistic syndrome: a case report with herpes simplex encephalitis. J of Aut and Dev Dis, 1986; 16:369-375.
Gillberg C, Coleman M: The Biology of the Autistic Syndromes 2nd Ed London. MacKeith Press. 1992.
Gillberg IC, Gillberg C, Kopp S, et al: Hypothyroidism and autism spectrum disorders. J Child Psychol Psychiat, March 1992; 33:3:531-42.
Gillberg C, Coleman M: Autism and medical disorders: a review of the literature. Dev Med Child Neurol. 1996; 38:191-202.
Gillberg C, Hagberg B, Witt-Engerstrom I, et al: CSF beta-endorphin in childhood neuropsychiatric disorders. Brain Dev, 1990; 12:88-92.
Gillberg IC: Autistic Syndrome with onset at age 31 years: herpes encephalitis as a possible model for childhood autism. Dev Med Child Neurol, Oct 1991; 33:10:920-924.
Gillberg IC, Gillberg C, Ahlsen G: Autistic behavior and attention deficits in tuberous sclerosis a population-based study. Dev Med Child Neurology, 1994; 36:50-56.

Denney DR, Frei BW, Gaffney, GR: Lymphocyte
subsets and interleukin-2 receptors in autistic children. J Autism Dev Dis, 1996; 26: 1.

Ivarsson SA, Bjerre I, Vegfors P, et al: Autism as one of several disabilities in two children with congenital cytomegalovirus infection. Neuroped, 1990; 21:102-103.
Wakefield AJ, et al: Ileal-lymphoid-nodular hyperplasia non-specific colitis and pervasive developmental disorder in children. The Lancet , Feb 28, 1999; 351(9103): 637-641.
Borody TJ Personal Communication, Centre for Digestive Diseases, New South Wales, Australia

Tvede M, Rask-Madsen J: Bacteriotherapy for chronic relapsing clostridium difficile diarrhoea in six patients. The Lancet , May 27, 1989; 1156-1160.
Feingold S: Veteran’s Hospital, Los Angeles, CA
Bolte, E: Autism and clostridium tetani. Med Hypoth, 1999; 51: 133-144.
Reichelt KL Nature and consequences of hyperpeptiduria and bovine casomorphins found in autistic syndromes. Dev Brain Dys, 1994; 7: 71-85.
Reichelt KL Biochemistry and psychophysiology of autistic syndromes. (Norwegian) Tidsskrift Den Norske Laegeforening, May 10, 1994; 114;12:1432-1434.
Shattock P, Kennedy A, Rowell F, et al: Role of neuropeptides in autism and their relationship with classical neurotransmitters. Brain Dysfunc, 1990; 3:328-245.
Shattock P, Lowdon G: Proteins, peptides, and autism Brain Dysfunc, 1991; 4: 323-324.
Williams K, Shattock P, Berney T Proteins, Peptides and Autism. Brain Dysfunct, 1991; 4:320-322.
Marchetti B, Scifo R, Batticane N, et al: Immunological significance of opioid peptide dysfunction in infantile autism. Brain Dysfunc, 1990; 3:346-354.
Lensing P, Schimke H, Panksepp J, et al: Clinical case report: opiate antagonist and event-related desynchronizatin in 2 autistic boys. Neuropsychobiol, 1995; 31:16-23.
LeBoyer M, Bouvard MP, Panksepp J, et al: Opioid excess hypotheses of autism: a double-blind study of Naltrexone. Brain Dysfunc, 1990; 3:285-298.
Herman B, Asleson G, Papero P: Acute and chronic Naltrexone decreases the hyperactivity of autism. Soc Neurosci (Abstr), 1993; 732:3.
Kolmen BK, Feldman HM, Handen BL, et al: Naltrexone in young autistic children: A double-blind placebo-controlled crossover study. J Am Acad Child Adolesc Psych, Feb 1995; 34:2.

Percy AK, Glaze DG, Schultz RJ: Rett syndrome:
controlled study of an oral opiate antagonist, Naltrexone. Ann Neurol, 1994; 35:464-470.

Cook E, Arora R, Anderson G: Platelet serotonin studies in hyperserotonemic relatives of children with autistic disorder. Life Sci, 1993; 52:2005-2015.
Cook E, Rowlett R, Jaselskis C: Fluoxetine treatment of patients with autism and mental retardation. J Am Child Adolesc Psych, 1992; 31:739-745.
Cook EH: Autism: review of neurochemical investigation. Synapse, 1990; 6: 292-308.
Cook EH, Fletcher KE, Wainwright M: Primary

structure of the human platelet serotonin 5-HT2 receptor: identity with frontal cortex serotonin 5-HT2A receptor. J Neurochem, 1994; 63:465-469.

Matson W Environmental Science Association (ESA), Chelmsford, MA
Friedman AE Ortho Clinical Diagnostics, Johnson & Johnson, Rochester, NY
D’Eufemia P, Celli M, Finochiaro R, et al: Abnormal intestinal permeability in children with autism. Acta Pediatr, 1995; 85:1076-9.
Bauman ML, Kemper TL: The neurobiology of autism. Baltimore, MD, Johns Hopkins Univ Press 1994.
Minshew N: In vivo brain chemistry in autism: 31P magnetic resonance spectroscopy studies In eds. Bauman, M, Kemper T. The neurobiology of autism. Baltimore, MD, Johns Hopkins Univ Press, 1994; 86-101.
Minshew NJ, Goldstein G, Dombrowski SM, et al: A preliminary 31P MRS study of autism: evidence for undersynthesis and increased degradation of brain membranes. Biol Psych, Jun 1-15 1993; 33:11-12:762-773.
Wilson J: Personal Communication, private clinician, Asheville, North Carolina
Luers G, Beier K, Hashimoto T, et al: Biogenesis of peroxisomes: sequential b iosynthesis of the membrane and matrix proteins in the course of hepatic regeneration. Europ J Cell Biol, 1990; 52:175-184.
Gibson GG, Lake B: Peroxisomes-biology and importance in toxicology and medicine. London. Taylor and Francis. 1993.

Moser HW, Moser AB: Very long-chain fatty acids in diagnosis, pathogenesis, and therapy of peroxisomal disorders. Lipids, 1996; 31:S141-
145.

Kane PC, Kane E: Peroxisomal disturbances in autistic spectrum disorder. J Orthomol Med, 1997; 12:4:207-218.
Herold S, Frakowiak RSJ, LeCouteur A, et al: Cerebral blood flow and metabolism of oxygen and glucose in young autistic adults. Psych Med, 1988; 18:823-831.
Gupta S, Rimland B, Schilling MS: Pento-xifylline: a brief review and a rationale for its potential use in the treatment of autism. J Child Neurol, Nov 1996; 11:6:501-504.

Jaselskis CA, Cook EH, Fletcher KE: Clonidine treatment of hyperactive and impulsive children with autistic disorder. J Clin Psychopharm, 1992;
12: 322-327.

Koshes RJ, Rock NJ: Use of clonidine for behavioral control in a patient with autism. Am J Psych, Nov 1994; 151:11.
Fankhauser MP, Karumanchi VC, German ML:

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