Autism Research Connections #3.5: A Conversation with Dr. Rosemary Waring

Dr. Rosemary Waring was interviewed by Seth Bittker on April 17, 2016 on sulfation deficits in autism, Epsom salts, the nature of autism, and prospects for future research.  Due to the poor quality of the audio recording, this interview will only be made available in transcript form. © 2016

Rosemary Waring

SB: This is Autism Research Connections [#3.5].  It is April 17, 2016.  I am your host, Seth Bittker, and our guest today is Dr. Rosemary Waring.  Dr. Waring has had a long and productive career as a research scientist focusing on metabolism and toxicology.  While she is technically retired, I have seen her name on a number of recent papers and she is an honorary reader in human toxicology at the School of Biosciences, University of Birmingham.  Dr. Waring is arguably the world expert on sulfur enzymes and the role of sulfation in inflammatory disease.  Specifically of great interest to our audience, Dr. Waring was the first to identify the sulfation deficits which often accompany autism.  Dr. Waring welcome to Autism Research Connections.

RW: Well thank you very much.  It is an honor and a pleasure.

SB: Thank you for being here.  Dr. Waring, what is sulfation?

RW: Sulfation is addition of a sulfur atom and four oxygen atoms, and makes everything more water soluble.

SB: Wonderful. And when the body does not have enough sulfate available what are some of the metabolic consequences?

RW: Well unfortunately sulfate is one of the major building blocks.  If you don’t have enough sulfate, you run into problems with sulfation of the gut mucins – these are proteins which line the gut.  You can also run into trouble because it is more difficult to form heparin sulfate and sulfated synovial fluid.  For instance you can get rheumatoid arthritis because you need sulfation for the joints to move and you can also have problems with sulfating neurotransmitters.

SB: Wow.  That is quite a picture.  Dr. Waring if I might highlight to our audience, you have published a series of remarkable papers starting in the mid-1990s on autism.  One is Biochemical Parameters in autistic children published in 1996.  Another is Sulphur Metabolism in Autism published in 2000 and I know you coauthored a number of other papers and perhaps I’m missing a few.  These are really significant findings.  Can you tell us what are those findings from your research regarding sulfation and autism?

RW: Well when we looked at children with autism we found that generally they had really quite low levels of sulfate in plasma and quite high levels in urine where the sulfate was leaking out.  Hence obviously this had a lot of knock on effects.

SB: That makes total sense.  What would some of those knock on effects be?

RW: For a start most people who we were looking at had gut problems, and they seemed to me to have so-called ‘leaky gut’.  They were much more susceptible to food intolerances I think because the food proteins get in through the gut wall to cause reactions much more easily.  You really rely on sulfating mucin proteins in the gut for their function.  If they are not sulfated, then you can get holes in between the mucins.  Obviously this will lead to a lot of problems.  So you can get gut problems, a number of children we looked at had neurotransmitter problems with high levels of serotonin and dopamine for instance, and many of them came from family backgrounds with rheumatoid arthritis.

SB: These are really important points.  So you are saying if somebody has leaky gut, they really should be looking at whether they have low levels of sulfate.  Is that correct?

RW: Well I think it is one of the main factors.  You see normally you rely on the gut to be non-permeable except for what you actually want to absorb.  The lining on the gut is renewed pretty regularly – about every three days, but if it has holes obviously that is not going to work in the same sort of way, and this is where the real trouble comes I think.

SB: That makes total sense.  So what happens to people who have reduced sulfation capacities in a world of chronic low grade exposure to xenobiotics?

RW: Well people are more susceptible to drugs.  For instance they tend to be more susceptible to what we in the UK call Paracetamol, what you call Tylenol.  And you also often find people are more susceptible to amines for example in cheese, chocolate, bananas, citrus fruit, and some parents of autistic children  have found their children have terrible reactions to these foods.  So it just creates all kinds of problems getting rid of quite ordinary things.

SB: This is terrific insight.  When we suspect there are issues with sulfation what are some of the most effective markers for flagging it?

RW: What I always suggested to people is that they try to increase the sulfate to see if that improves the problem.  I feel if you put more sulfate in and things get better, that tells us it was needed.

SB: That is a terrific low-tech, very practical solution.   I guess I also wonder does it make sense to look at markers of blood sulfur or not really?

RW: Well you can do it.  I think one of the problems is some of the markers for instance neurotransmitters  can be quite difficult to look at.  You could do spinal fluid couldn’t you, but that would be a bit much.  I really think it’s easier to put in more sulfate to see if things feel better.  Because you get such different things reacting to sulfate it is impossible to say if you see X, then Y.

SB: That is wonderfully practical advice.  I know a lot of children with autism have issues with sulfate.  Do you have an estimate of what percentage of the children – I should say individuals because many are not children – with autism have abnormalities of sulfation?

RW: Well we looked a series of about 150 children with autism – this was just a random sample really – and about 60% had issues with sulfate – a significant issue.

SB: …Do you recall what the definition used of issues with sulfate is?

RW: Well these were children who had a lot of gut problems.  They are the ones that had the lowest levels.  We did find low levels in all of them, but I think they were lowest in the children with gut trouble.

SB: Very fair.  So is the sulfate deficit in autism due to excess exposure to chemicals – xenobiotics, inadequate consumption of sulfur containing compounds, or is genetic predisposition?

RW: Well I think it is all three potentially because we know one of the problems with sulfate is that is not that easy to absorb huge amounts of it.  You usually rely on cysteine and methionine – the amino acids sulfur and most of the work is done by cysteine dioxygenase and sulfite oxidase.  It is a design fault because these enzymes are easily inhibited.  You can have people who have an ineffective enzyme for a start.  You can have people where an enzyme is being inhibited by various factors.  You can people who don’t have much sulfate in the diet.  You can have people who seem to have an overload of xenobiotics who have depleted their sulfate.

SB: It makes complete sense.  You mentioned in some instances that it may be a defect of genetics.  Does this indicate that as a species we are not adapted to some of the exposures we are getting?

RW: Well I think some people are less able than others.  There is a huge spectrum.  For instance drinking alcohol, now we all know somebody who perhaps will drink half a pint of beer and is really pretty drunk at the end of it, and other people who drink half a bottle of whisky and you would never know they had been drinking.  There is huge variation with response to alcohol and huge variation with response to drugs.  I think that what makes autism quite difficult to explain to lay people is to say that there is this variation.

SB: That makes sense.  Your research also shows that sulfation abnormalities seem to be connected to a number of other degenerative and autoimmune diseases such as rheumatoid arthritis and ulcerative colitis.  What typically comes first in your view, sulfation deficits leading to immune dysfunction or immune dysfunction leading to sulfation deficits?

RW: Oh it is immune dysfunction leading to sulfation deficits.  When we looked at human cysteine dioxygenase which is the principal enzyme to form sulfate ions, it is inhibited by pretty much all the cytokines in the inflammatory process, where TNF-alpha is the major one.  So if you have any inflammation as in rheumatoid arthritis for instance you get a high level of TNF-alpha and you knock down the level of sulfate.  So you get what you do see in RA which is a sort of spiral where you get worse and worse.

SB: I see.  That is a really good point.  So putting this back in an autism context if somebody has a low sulfate and potentially autoimmunity associated with it, you can maybe add a sulfation agonist to the diet and that may help some but it may not get at the underlying dysfunction.  Is that what you are saying?

RW: Yes.  As a matter of fact I think nobody has ever tried it, but some children [with autism] have high levels of TNF-alpha.  Now in rheumatoid arthritis you prescribe the antibodies to TNF-alpha which have been really very successful.  Would it work in autism?  I don’t know, we have never tried.

SB: It’s a great question, and I hope somebody looks at that.   I think there are some people who have done intravenous immunoglobulin in autism as a similar sort of thing and some work and some don’t.  Do you have any comments or thoughts on that?

RW: I don’t know, I have never tried it myself.  I am not a clinician.  I have talked to some people who tried it and they say sometimes it helps.  I think the real trouble is we don’t know who would benefit.

SB:  That’s a very good point.  Are there certain markers that you think people ought to look at?

RW: I don’t know.  It would be interesting to look at those children who had those treatments and had who benefited and see what the markers were opposed to those who did not benefit.

SB:  Wonderful.  We have been talking a lot about this sulfur deficit in autism – or sulfate deficit excuse me – I should say.  What therapies are most effective at remedying the sulfation deficits that we often see in autism?

RW: Well I think one of the most helpful ones is Epsom salts.  You can have a bath in it.  You have people who wash their hair with Epsom salts and that works perfectly, and you can actually put it against the skin with a plaster to hold it on.

SB: That is fascinating and I am glad you brought this up.  So for our audience we are talking about magnesium sulfate – Epsom salts.  I believe you.  You know this stuff but can you give us some information on what evidence there is that this actually works?

RW: Well we have looked at it in normal people.  I have never looked at it clinically in autism.  In normal people if you have an Epsom salt bath you do get much higher levels of sulfate in plasma, with  more coming out in urine.  You don’t see much change in magnesium because in normal people magnesium is very tightly controlled.  So there shouldn’t be much change and you don’t see any.  In children with autism I  know people who have talked to me or phoned have told me it is very helpful.  I don’t think people will phone all the way from Australia to the UK unless they mean it.  It has to work.

SB: That is wonderful.  I have seen I believe some of your research on Epsom salts effectiveness posted on a website.  Is this in the medical literature or is this more tests you have run if not formally published?

RW: Oh there were certainly tests that we formally published.  I had a lot of trouble finding a journal that would take it, and rather left it for a bit and did a little more work.  And then a colleague of mine in London used magnesium sulfate and was able to show that it crosses the skin.  Now if anybody asked, I would have said it doesn’t, but it certainly did.  So that was interesting.  We have written a review that I guess is out either now or very shortly in Xenobiotica.  I think it is there electronically.  It is all about transport across the skin – across biological membranes, but in fact when we looked at the literature we found that quite a few other people had shown that Epsom salt cross the skin.  So it is an interesting finding.

SB: It is.  It is wonderful and it is very important.  [Are] there other things that people who have issues with sulfation or sulfation deficits might want to consider doing in terms of I think you mentioned cysteine and methionine – or is that something that is too complicated?

RW: Well if the sulfur oxidation was faulty this might not work terribly well, and all amino acids are toxic anyway.  You could certainly try to take a small amount.  I know some people take methylsulfonylmethane (MSM) and say that is helpful.  You don’t know what the problem is in any given individual, and so the thing to do is to try a small amount and see what works.

SB: That makes a lot of sense.  You made an interesting point there about amino acids being toxic.  I imagine we are talking about a dose effect, correct?

RW: Yes.  You certainly don’t want to take any more than about 200 mg of any amino acid and you would not want to do it often.

SB: Very fair…  On the Epsom salts, if the Epsom salts go through the skin, and it sounds like there is very good research that they do, what is to keep them from going through the skin and you getting an overload?

RW: Well you probably do because people who have tried it have usually told me that the best thing to do is to have baths perhaps two or three times a week for three weeks and then stop for three weeks and then start up again.  I would assume because they are talking about headache here we are talking about some kind of overload.  Not of sulfate because we get rid of that quite easily but probably magnesium.

SB: That is fascinating.  I honestly did not expect that answer.  I was thinking… let’s say you go into the ocean would you also get the same effect or is it just with concentrated magnesium sulfate?

RW: Well I don’t know.  We have never looked.  I would think you would get the same effect.  I think it goes across better if the water is warm.  Perhaps you could get it in the Pacific Ocean?

SB: Very interesting. If you are absorbing sulfate is this also affecting levels of other sulfur containing compounds such as things like cysteine and methionine?

RW: We don’t know.  We have never looked.  I would think not.  Sulfate is pretty much a sort of end product.  You can have quite high levels in plasma without any ill effects.  It just comes out through the kidneys.

SB: Wonderful.  Are there drugs or other compounds that we should avoid providing to those with autism who also have associated sulfation deficits?

RW: Oh.  It depends on the drug.  I would certainly be happy to not use Paracetamol.  Your Tylenol… You would have to look at the metabolism of the individual drug and see whether it did affect sulfate.  Offhand I can’t think of any specific ones.  No family of drugs.

SB: That is very interesting, and with respect to Paracetamol or Acetaminophen, I think there is some research indicating that people who have higher rates of use have higher rates of autism.  Does your research on this give that associated research some additional credence?

RW: That’s what people have told me…. It is the impression I have got.

SB: That’s wonderful.  Are there research groups working on extending your sulfation research in autism today?

RW: Well yes.   There is Jim Adams in Arizona.  Isn’t he at Arizona State?  He has done a lot of work on autism and certainly replicated our sulfate results and as far as I know he is continuing that line.

SB: I am glad you brought his work up.  Just as an observer of all this it does seem to me when Jim Adams not only reproduces your work on low sulfate in the blood but also has a high sulfur multivitamin which provides benefit to many with autism in some ways he is validating what you have already found.  Would you agree?

RW: Yes.  I think highly of his work.  I think he has done some very good stuff, and it is in line with a lot of work in the literature.  Funnily enough there is a mouse model for autism and this mouse has low levels of sulfate as well.  It is a basic problem.

SB: It really makes sense.  Dr. Waring should we be talking about autism as a single disease entity or autisms?

RW: Well it isn’t a single disease.  I think it is one of the problems in the field that a lot of researchers tend to take what looks like a rather heterogeneous set of children and then try to get sense out of it.  Certainly… with 150 children, obviously that is a very small number, we were able to go into three main groups.  So the problem is that we have got other groups out there.

SB: And what were those three main groups?  Do you recall?

RW: Well about 60% had gut problems and they came from families with autoimmune dysfunction of some sort – rheumatoid arthritis, ulcerative colitis, eczema, asthma, all that stuff.  They seemed to be very different from other groups.  About 15% of the children had what I think are damaged hypothalamus pathways.  They tended to be very thirsty – to drink gallons of liquid if they could get it – obviously had problems with vasopressin levels.  This is damage pre-birth.  Then there was a last group, about 20 plus percent, who I think had frontal lobe damage.  They tended to have problems with handedness and had very vivid dreams.  They seemed to be much more autistic than the children with gut problems.

SB: That is really interesting stuff.  So when you split these children up into these different groups were there any markers with which you could do it or are you doing this all based on observation?

RW: We asked the parents/carers to fill in two sided A4 questionnaires.  You can’t make it too detailed because otherwise [they won’t fill it in] but it was quite enough to divide children into one of the three groups.  I always thought if we had a much larger group and a more detailed questionnaire you could get more detailed grouping, but they were very different biochemically and in autistic features.  So I have always felt that autism is a catch-all term.  It is a bit like saying you have an infection but this could be caused by any number of things.

SB: That makes complete sense.  So I believe if I am understanding you correctly you would only think of suflate as a potential therapy in the group that has 60% gut problems or would you be thinking of it in all groups?

RH: Well it did work in all groups, but the ones that responded the best were the ones with gut problems.

SB: That makes sense.  I know that you are not a clinician, but from your other work in biochemistry are there other types of over-the-counter supplements or treatments that people in that gut problems group should be given or at least have as a trial?

RW: I can’t think of anything off hand that is really for gut problems, and I think that is one reason why [they] are so intractable and people usually respond by going on a casein free / gluten free diets which seem to work in some children.

SB: That is a great point, and this is something that I know there still seems to be some debate about. On the casein free / gluten free diet, how does that connect in with your sulfur research?

RW: Well we looked at this in some detail but not in a very large number of children.  One of the problems with casein is that it is  obviously broken down in the gut by peptidases like all proteins.  In fact casein is not that easy to breakdown and some people are much better at it than others.  One of the basic problems is that you have a sequence in which you sulfate a protein called gastrin which is obviously in the stomach, and the sulfated gastrin then causes release of sulfated enzymes in the pancreas which lead to breakdown of carbohydrates, lipids, and proteins.  But if that initial sulfation and further sulfation of the enzymes does not occur, then you don’t get breakdown of proteins into amino acids or tiny peptides.  You get quite long peptides and if you then have a leaky gut as well, I think these peptides get into the blood stream and that gives you the cause of the problems.

SB: This is a wonderful portrait you have just painted.  It makes complete theoretical sense, and I have seen lots of anecdotal reports.  It works.  I actually happen to be one of those that believe that it works.  At least from my reading research is mixed on whether it is effective or not – say in a double blinded trial.  Do you have any thoughts or comments on that?

RW: Well actually I think it is very difficult to do a true double blinded trial on something like that.  I think that is a basic problem.  Again I find myself saying, try it out, it should work in two to three weeks max.  If it seems to help then go on with it.  If it doesn’t, then don’t bother with it.

SB: This is one of the wonderful things I am learning about you. You are intensely practical Dr. Waring, and that is a wonderful characteristic for those of us who are trying to understand some of your research and apply it.

RW: Well it is no use having things that are too complicated.  I think it is quite difficult if you have children with autism to go on a really complex diet, and then there is the rest of the family to consider and so on.  I think it is only worth it if they seem to benefit.

SB: That’s wonderful.  What other autism research that you have seen in recent years do you feel holds significant promise?

RW: What has been really exciting in recent years is the rise in the number of studies that have shown that children with autism have high levels of cytokines – the markers released in inflammation.  Now what we don’t understand is why they have got these levels.  Often the siblings have medium high levels.  Well there is obviously a family problem.  Why are they up?  Everybody has raised level of cytokines with an infection, but why don’t they go down to normal?  There is obviously a basic problem with the immune system.  In studies in children on autism – the little one we did with about 100 children, mothers were 6.4 times more likely to take antibiotics during pregnancy.  Now that is a huge difference isn’t it, given that they really don’t like to give anything if you’re pregnant.  So that is quite serious.

SB: That is a very big clue.  So it almost sounds like are you saying there is immune dysfunction and that is related back to the gut presumably.  Is that correct?

RW: Yes.  I think there is immune dysfunction, and I think this means that the brain tissue of the fetus as it is developing is not laid down as it should be.  Certainly in the mouse model they have less sulfated heparin for instance and less sulfation of brain markers as well.  So as I see it, what happens is you get some sort of infection in the mother.  For some reason it does not die away.  Perhaps she has persistent chronic infection.  We really don’t understand that much about the immune system.  This then leads to trouble when the baby’s brain is being formed.

SB: That makes complete sense.  If it was that particular case, why would the baby’s immune system be affected longer term?

RW: Well the bottom line is that we don’t know.  There is nothing that really explains it.  Why the baby’s immune system doesn’t drop back down to normal?  But they don’t.  They appear to have chronic inflammatory conditions which they don’t clear properly.

SB: Makes sense.  Dr. Waring is there anything else you would like out audience to know?

RW: Well what I would like to see for autism long term is to look at the epigenetics.  These are where environmental factors don’t affect the original DNA but what they affect is the reading of that DNA.  So they turn the reading of that DNA on or off.  Now I think if we can show epigenetic effects as well as other things, this will really give us a clue on what environmental triggers to avoid.

SB: This a very important point.  What kinds of studies would show epigenetic affects?

RW: You could take a group of children with autism and look at epigenetic variations of some common proteins – methylation in particular.  Anyway you look at the DNA and just see what the differences are in methylation patterns.

SB: That’s fascinating.  Is there anything else you think we should be looking at?

RW: Well not really.  A better understanding of inflammation in general would probably be the most helpful thing.

SB: That makes complete sense.  Dr. Waring thank you for this interview, and thank you for being with us on Autism Research Connections.

RW: Well I’ve enjoyed it.  It has been a pleasure.  Thank you very much for asking me.