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      Frequently Asked Questions About Celiac Disease   04/07/2018

      This Celiac.com FAQ on celiac disease will guide you to all of the basic information you will need to know about the disease, its diagnosis, testing methods, a gluten-free diet, etc.   Subscribe to Celiac.com's FREE weekly eNewsletter   What are the major symptoms of celiac disease? Celiac Disease Symptoms What testing is available for celiac disease?  Celiac Disease Screening Interpretation of Celiac Disease Blood Test Results Can I be tested even though I am eating gluten free? How long must gluten be taken for the serological tests to be meaningful? The Gluten-Free Diet 101 - A Beginner's Guide to Going Gluten-Free Is celiac inherited? Should my children be tested? Ten Facts About Celiac Disease Genetic Testing Is there a link between celiac and other autoimmune diseases? Celiac Disease Research: Associated Diseases and Disorders Is there a list of gluten foods to avoid? Unsafe Gluten-Free Food List (Unsafe Ingredients) Is there a list of gluten free foods? Safe Gluten-Free Food List (Safe Ingredients) Gluten-Free Alcoholic Beverages Distilled Spirits (Grain Alcohols) and Vinegar: Are they Gluten-Free? Where does gluten hide? Additional Things to Beware of to Maintain a 100% Gluten-Free Diet What if my doctor won't listen to me? An Open Letter to Skeptical Health Care Practitioners Gluten-Free recipes: Gluten-Free Recipes
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    GLUTEN-FREE BEER


    Leszek Jaszczak


    • Journal of Gluten Sensitivity Spring 2013 Issue


    Celiac.com 04/15/2017 - Raw materials used by breweries include barley. A characteristic feature of this grain is the presence of gluten proteins which also includes hordein. This group of proteins are the trigger of celiac disease symptoms [Darewicz, Dziuba, Jaszczak: "Celiakia – aspekty molekularne, technologiczne, dietetyczne." PrzemysÅ‚ Spożywczy, styczeÅ„, 2011] . This issue raises the need to seek new methods of brewing that allow for the elimination of gluten proteins from the beer [swora E., Stankowiak-Kulpa H., Mazur M. 2009. Dieta bezglutenowa w chorobie trzewnej. Nowiny Lekarskie 78, 5-6, 324-329]. The biggest problem for coeliac patients is to identify permitted foods. Food manufacturers know about the above problem and are offering new products for people with celiac disease. [CichaÅ„ska B.A., 2009. Problemy z rozróżnianiem żywnoÅ›ci bezglutenowej. Pediatria WspóÅ‚czesna. Gastroenterologia, Hepatologia i Å»ywienie Dziecka 2009, 11, 3, 117-122.] The market offers access to a gluten-free beer. Beer of this type can be prepared in one of two ways, either by using materials that do not contain gluten or by removing gluten during the production of beer. Such products are, however, expensive. Traditional market beers are not tested for gluten content, which may differ from one brand to the next.


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    Barley, hops, yeast and water are the basic raw materials for conventional beer production. Gluten in beer is only in the barley or wheat, from which malt is produced. During malting, barley is subjected to the processes of soaking, germination and drying. At that time, amylolytic and proteolytic enzyme activity increases and grain composition is undergoing changes. Knowledge about the migration through various stages of beer production and the final level of these proteins or their "toxic" fractions is crucial to ensuring customers about the safety of the beverage they will consume. Therefore, it is important to conduct research to better understand the role and the amount of unwanted hordein and/or wheat prolamin in the production of beer. Malt has become a subject of research because of its harmful potential for patients with celiac disease.

    In a study conducted by Czech scientists different species of barley, malt and beer were analyzed. Beers analyzed for gluten content were characterized by very different gluten contents. The level of gluten in raw cereals ranges from 18-68 g/kg. After comparing the different types of beers, in terms of the gluten concentration, the results were as follows:
    non-alcoholic beer

    Raw seed contained 50.4 ± 1.8 g per kg of gluten and comparing to it malt 68 ± 4 g per kg of gluten. Higher levels of gluten in malt have been confirmed in studies on other types of barley and other crops derived from a corresponding malt from which they were produced under similar conditions.

    Malt barley grains are subjected to extraction during mashing. Gluten content was examined during the entire production process. The amount of protein decreases during the production process due to precipitation of proteins in the fermentation mash, at the adsorption stage, and during beer stabilization. Researchers say that the gluten content in beer is about three times lower than in the raw barley grain. The gluten content changes at each stage of the beer production as is shown below:
    malt> sweet wort> wort after chop adding > beer> stabilized beer.

    Most of the proteins in the sharps (milled barley) are extracted which is a remnant of the filtration process in the mash tun (the vessel where the wort is boiled). Only a small part of the gluten goes to sweet wort – 1.75%. A slight decrease was recorded after the boiling process with the addition of hops -1.7%. During the fermentation process the pH decreases, this causes the precipitation of the polypeptides and their adsorption on the surface of yeast cells. Only 0.21% of the initial gluten content remains in the beer. After the filtration process beer is subjected to colloidal stabilization with PVPP - polyvinylpolypyrrolidone and silico gel (kiesegel) and then they are removed. This process results in lowering gluten content to less than 0.11% of the initial gluten content of barley [immunochemical determination of gluten in Malts and Beers, Food Additives and Contaminants; TFAC-2005-365.R1, 29-Mar-2006; Dostálek, Pavel; Institute of Chemical Technology, Prague, Department of Fermentation and Bioengineering Chemistry].

    The researchers used three methods to test the gluten content of beer. Their results differ from each other. Results show that to accurately estimate the amount of proteins and peptides dangerous to people with celiac disease, we must first develop a good methodology for the analysis. This will give the exact content of these harmful substances and provide real security to customers. If we use the method demonstrating the largest gluten protein content, only 30% of the samples were safe for patients. According to the authors there is no safe beer brewed from barley or wheat if we accept that the maximum tolerable daily intake of gluten is 10 mg. The law of the European Commission says that gluten-free food must contain less than 20 mg. per kg. Proteins present in the beers are removed during production through product stability and are hydrolysed by proteolytic enzymes present in the various stages of production. Partially hydrolyzed prolamines contained in beer are still "toxic peptides"- short protein fragments containing from a few to several amino acid residues. These fragments, rich in proline, trigger a series of reactions from the immune system, leading to celiac disease [Commission Regulation (European Communities) No 41/2009 of 20 January 2009, the Official Journal of the European Union, 21.1.2009, L 16 / 3].

    The most obvious method for the production of gluten-free beer is to use only gluten-free raw materials. In the production of such a beer a lot of attention must be paid to remove unwanted components from the beer. Technologists involved in the production of beer specialize in the removal of proteins from beer and controlling their levels, as they can reduce colloidal stability of the beer flavor. Removing or reducing the amount of these proteins may be a way to achieve our goal.

    Confounding factors in the production of gluten-free beer can be:

    • Selection of barley varieties with a low content of protein and the corresponding enzymatic apparatus;
    • Mashing process modified by deeper proteolysis, similar methods are used in the manufacture of gluten-free bread searching for enzymes capable of degrading specific proteins and peptides;
    • Methods of striving for maximum distribution and precipitation of proteins with the use of adsorbents;
    • The use of proteolytic enzymes in the production and stabilization of fermentation, such as amyloglucosidase is used to improve fermentation or β-glucanase to reduce viscosity. The enzyme used in the end may be proline endopeptidase;
    • Implementation of the adsorbent during the stabilization phase of beer to remove residual proteins and peptides.

    Conventional materials can be used, if the genetically modified seeds will be devoid of genes responsible for the production of gliadin. However, such seeds are not yet available and the use of transgenic food additives is prohibited in many countries.

    Modification of the enzymes to reduce the gluten content can be achieved in two ways. Genetically modified yeast capable of expressing specific enzymes capable of degrading the protein can be used, or adding the enzyme - transglutaminase - directly during the production can also be done. These methods each have their own advantages, because with the right methodology a beer can be produced without loss of its natural taste.

    Another method of manufacture of gluten-free beer is the use of cereals rich in carbohydrates that do not contain gluten. These include amaranth, buckwheat, quinoa, sorghum, millet, corn, and rice.
    We can also add raw materials, the lack of native amylolytic enzymes must be compensated by the addition of external enzymes. However, this is a factor which increases costs. Colorants and flavorings also have to be added [Celiac Disease, Beer and Brewing, Michael J. Lewis, Emeritus Professor of Brewing Science Department of Food Science and Technology, University of California Davis].

    Gluten-free raw materials
    Cereals that are not taxonomically close to wheat, barley and rye are safe for people with celiac disease. Potential sources of gluten-free beer include: sorghum, corn, brown rice, millet, teff, buckwheat, and amaranth. At present, one of the best gluten-free beer production methods is to use gluten-free raw materials and avoid any cross-contamination. Gluten-free beer production technology is not a new technology. Some African tribes have produced beer based on sorghum and corn for 20 years. It turns out that buckwheat has a large potential for the production of gluten-free beer. Even unhulled seeds can be used. Husks can be used as the filtering material in the filter vat. The resulting malt is characterized by a taste reminiscent of toffee with a slightly nutty flavor.

    One of the major problems with buckwheat beer production is very low enzyme activity. It is several times lower than in barley enzymes. In addition, the high content of polysaccharides increases the viscosity of the solution. However, through rheological tests scientists have developed optimal methods in pilot studies and demonstrated that it is possible to produce a gluten-free beer with buckwheat. [brewing New technologies, CW Bamforth Published by Woodhead Publishing Limited, Abington Hall, Abington, Cambridge CB1 6AH, England, First published 2006, Woodhead Publishing Limited and CRC Press LLC ß 2006, Woodhead Publishing Limited].

    As the diagnostic methods for identifying celiac disease improve every year and more and more people are diagnosed with coeliac disease, the demand for this kind of drink will continue to grow. In addition, new types of beer can attract people who are interested in trying new tastes and making alternative choices.



    Image Caption: Photo: CC--Mr Hicks46
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    Jefferson Adams
    Celiac.com 04/19/2018 - Previous genome and linkage studies indicate the existence of a new disease triggering mechanism that involves amino acid metabolism and nutrient sensing signaling pathways. In an effort to determine if amino acids might play a role in the development of celiac disease, a team of researchers recently set out to investigate if plasma amino acid levels differed among children with celiac disease compared with a control group.
     
    The research team included Åsa Torinsson Naluai, Ladan Saadat Vafa, Audur H. Gudjonsdottir, Henrik Arnell, Lars Browaldh, and Daniel Agardh. They are variously affiliated with the Institute of Biomedicine, Department of Microbiology & Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; the Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; the Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital and Division of Pediatrics, CLINTEC, Karolinska Institute, Stockholm, Sweden; the Department of Clinical Science and Education, Karolinska Institute, Sodersjukhuset, Stockholm, Sweden; the Department of Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden; the Diabetes & Celiac Disease Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden; and with the Nathan S Kline Institute in the U.S.A.
    First, the team used liquid chromatography-tandem mass spectrometry (LC/MS) to analyze amino acid levels in fasting plasma samples from 141 children with celiac disease and 129 non-celiac disease controls. They then crafted a general linear model using age and experimental effects as covariates to compare amino acid levels between children with celiac disease and non-celiac control subjects.
    Compared with the control group, seven out of twenty-three children with celiac disease showed elevated levels of the the following amino acids: tryptophan; taurine; glutamic acid; proline; ornithine; alanine; and methionine.
    The significance of the individual amino acids do not survive multiple correction, however, multivariate analyses of the amino acid profile showed significantly altered amino acid levels in children with celiac disease overall and after correction for age, sex and experimental effects.
    This study shows that amino acids can influence inflammation and may play a role in the development of celiac disease.
    Source:
    PLoS One. 2018; 13(3): e0193764. doi: & 10.1371/journal.pone.0193764

    Jefferson Adams
    Celiac.com 04/18/2018 - To the relief of many bewildered passengers and crew, no more comfort turkeys, geese, possums or other questionable pets will be flying on Delta or United without meeting the airlines' strict new requirements for service animals.
    If you’ve flown anywhere lately, you may have seen them. People flying with their designated “emotional support” animals. We’re not talking genuine service animals, like seeing eye dogs, or hearing ear dogs, or even the Belgian Malinois that alerts its owner when there is gluten in food that may trigger her celiac disease.
    Now, to be honest, some of those animals in question do perform a genuine service for those who need emotional support dogs, like veterans with PTSD.
    However, many of these animals are not service animals at all. Many of these animals perform no actual service to their owners, and are nothing more than thinly disguised pets. Many lack proper training, and some have caused serious problems for the airlines and for other passengers.
    Now the major airlines are taking note and introducing stringent requirements for service animals.
    Delta was the first to strike. As reported by the New York Times on January 19: “Effective March 1, Delta, the second largest US airline by passenger traffic, said it will require passengers seeking to fly with pets to present additional documents outlining the passenger’s need for the animal and proof of its training and vaccinations, 48 hours prior to the flight.… This comes in response to what the carrier said was a 150 percent increase in service and support animals — pets, often dogs, that accompany people with disabilities — carried onboard since 2015.… Delta said that it flies some 700 service animals a day. Among them, customers have attempted to fly with comfort turkeys, gliding possums, snakes, spiders, and other unusual pets.”
    Fresh from an unsavory incident with an “emotional support” peacock incident, United Airlines has followed Delta’s lead and set stricter rules for emotional support animals. United’s rules also took effect March 1, 2018.
    So, to the relief of many bewildered passengers and crew, no more comfort turkeys, geese, possums or other questionable pets will be flying on Delta or United without meeting the airlines' strict new requirements for service and emotional support animals.
    Source:
    cnbc.com

    admin
    WHAT IS CELIAC DISEASE?
    Celiac disease is an autoimmune condition that affects around 1% of the population. People with celiac disease suffer an autoimmune reaction when they consume wheat, rye or barley. The immune reaction is triggered by certain proteins in the wheat, rye, or barley, and, left untreated, causes damage to the small, finger-like structures, called villi, that line the gut. The damage occurs as shortening and villous flattening in the lamina propria and crypt regions of the intestines. The damage to these villi then leads to numerous other issues that commonly plague people with untreated celiac disease, including poor nutritional uptake, fatigue, and myriad other problems.
    Celiac disease mostly affects people of Northern European descent, but recent studies show that it also affects large numbers of people in Italy, China, Iran, India, and numerous other places thought to have few or no cases.
    Celiac disease is most often uncovered because people experience symptoms that lead them to get tests for antibodies to gluten. If these tests are positive, then the people usually get biopsy confirmation of their celiac disease. Once they adopt a gluten-free diet, they usually see gut healing, and major improvements in their symptoms. 
    CLASSIC CELIAC DISEASE SYMPTOMS
    Symptoms of celiac disease can range from the classic features, such as diarrhea, upset stomach, bloating, gas, weight loss, and malnutrition, among others.
    LESS OBVIOUS SYMPTOMS
    Celiac disease can often less obvious symptoms, such fatigue, vitamin and nutrient deficiencies, anemia, to name a few. Often, these symptoms are regarded as less obvious because they are not gastrointestinal in nature. You got that right, it is not uncommon for people with celiac disease to have few or no gastrointestinal symptoms. That makes spotting and connecting these seemingly unrelated and unclear celiac symptoms so important.
    NO SYMPTOMS
    Currently, most people diagnosed with celiac disease do not show symptoms, but are diagnosed on the basis of referral for elevated risk factors. 

    CELIAC DISEASE VS. GLUTEN INTOLERANCE
    Gluten intolerance is a generic term for people who have some sort of sensitivity to gluten. These people may or may not have celiac disease. Researchers generally agree that there is a condition called non-celiac gluten sensitivity. That term has largely replaced the term gluten-intolerance. What’s the difference between celiac disease and non-celiac gluten-sensitivity? 
    CELIAC DISEASE VS. NON-CELIAC GLUTEN SENSITIVITY (NCGS)
    Gluten triggers symptoms and immune reactions in people with celiac disease. Gluten can also trigger symptoms in some people with NCGS, but the similarities largely end there.

    There are four main differences between celiac disease and non-celiac gluten sensitivity:
    No Hereditary Link in NCGS
    Researchers know for certain that genetic heredity plays a major role in celiac disease. If a first-degree relative has celiac disease, then you have a statistically higher risk of carrying genetic markers DQ2 and/or DQ8, and of developing celiac disease yourself. NCGS is not known to be hereditary. Some research has shown certain genetic associations, such as some NCGS patients, but there is no proof that NCGS is hereditary. No Connection with Celiac-related Disorders
    Unlike celiac disease, NCGS is so far not associated with malabsorption, nutritional deficiencies, or a higher risk of autoimmune disorders or intestinal malignancies. No Immunological or Serological Markers
    People with celiac disease nearly always test positive for antibodies to gluten proteins. Researchers have, as yet, identified no such antobodies or serologic markers for NCGS. That means that, unlike with celiac disease, there are no telltale screening tests that can point to NCGS. Absence of Celiac Disease or Wheat Allergy
    Doctors diagnose NCGS only by excluding both celiac disease, an IgE-mediated allergy to wheat, and by the noting ongoing adverse symptoms associated with gluten consumption. WHAT ABOUT IRRITABLE BOWEL SYNDROME (IBS) AND IRRITABLE BOWEL DISEASE (IBD)?
    IBS and IBD are usually diagnosed in part by ruling out celiac disease. Many patients with irritable bowel syndrome are sensitive to gluten. Many experience celiac disease-like symptoms in reaction to wheat. However, patients with IBS generally show no gut damage, and do not test positive for antibodies to gliadin and other proteins as do people with celiac disease. Some IBS patients also suffer from NCGS.

    To add more confusion, many cases of IBS are, in fact, celiac disease in disguise.

    That said, people with IBS generally react to more than just wheat. People with NCGS generally react to wheat and not to other things, but that’s not always the case. Doctors generally try to rule out celiac disease before making a diagnosis of IBS or NCGS. 
    Crohn’s Disease and celiac disease share many common symptoms, though causes are different.  In Crohn’s disease, the immune system can cause disruption anywhere along the gastrointestinal tract, and a diagnosis of Crohn’s disease typically requires more diagnostic testing than does a celiac diagnosis.  
    Crohn’s treatment consists of changes to diet and possible surgery.  Up to 10% of Crohn's patients can have both of conditions, which suggests a genetic connection, and researchers continue to examine that connection.
    Is There a Connection Between Celiac Disease, Non-Celiac Gluten Sensitivity and Irritable Bowel Syndrome? Large Number of Irritable Bowel Syndrome Patients Sensitive To Gluten Some IBD Patients also Suffer from Non-Celiac Gluten Sensitivity Many Cases of IBS and Fibromyalgia Actually Celiac Disease in Disguise CELIAC DISEASE DIAGNOSIS
    Diagnosis of celiac disease can be difficult. 

    Perhaps because celiac disease presents clinically in such a variety of ways, proper diagnosis often takes years. A positive serological test for antibodies against tissue transglutaminase is considered a very strong diagnostic indicator, and a duodenal biopsy revealing villous atrophy is still considered by many to be the diagnostic gold standard. 
    But this idea is being questioned; some think the biopsy is unnecessary in the face of clear serological tests and obvious symptoms. Also, researchers are developing accurate and reliable ways to test for celiac disease even when patients are already avoiding wheat. In the past, patients needed to be consuming wheat to get an accurate test result. 
    Celiac disease can have numerous vague, or confusing symptoms that can make diagnosis difficult.  Celiac disease is commonly misdiagnosed by doctors. Read a Personal Story About Celiac Disease Diagnosis from the Founder of Celiac.com Currently, testing and biopsy still form the cornerstone of celiac diagnosis.
    TESTING
    There are several serologic (blood) tests available that screen for celiac disease antibodies, but the most commonly used is called a tTG-IgA test. If blood test results suggest celiac disease, your physician will recommend a biopsy of your small intestine to confirm the diagnosis.
    Testing is fairly simple and involves screening the patients blood for antigliadin (AGA) and endomysium antibodies (EmA), and/or doing a biopsy on the areas of the intestines mentioned above, which is still the standard for a formal diagnosis. Also, it is now possible to test people for celiac disease without making them concume wheat products.

    BIOPSY
    Until recently, biopsy confirmation of a positive gluten antibody test was the gold standard for celiac diagnosis. It still is, but things are changing fairly quickly. Children can now be accurately diagnosed for celiac disease without biopsy. Diagnosis based on level of TGA-IgA 10-fold or more the ULN, a positive result from the EMA tests in a second blood sample, and the presence of at least 1 symptom could avoid risks and costs of endoscopy for more than half the children with celiac disease worldwide.

    WHY A GLUTEN-FREE DIET?
    Currently the only effective, medically approved treatment for celiac disease is a strict gluten-free diet. Following a gluten-free diet relieves symptoms, promotes gut healing, and prevents nearly all celiac-related complications. 
    A gluten-free diet means avoiding all products that contain wheat, rye and barley, or any of their derivatives. This is a difficult task as there are many hidden sources of gluten found in the ingredients of many processed foods. Still, with effort, most people with celiac disease manage to make the transition. The vast majority of celiac disease patients who follow a gluten-free diet see symptom relief and experience gut healing within two years.
    For these reasons, a gluten-free diet remains the only effective, medically proven treatment for celiac disease.
    WHAT ABOUT ENZYMES, VACCINES, ETC.?
    There is currently no enzyme or vaccine that can replace a gluten-free diet for people with celiac disease.
    There are enzyme supplements currently available, such as AN-PEP, Latiglutetenase, GluteGuard, and KumaMax, which may help to mitigate accidental gluten ingestion by celiacs. KumaMax, has been shown to survive the stomach, and to break down gluten in the small intestine. Latiglutenase, formerly known as ALV003, is an enzyme therapy designed to be taken with meals. GluteGuard has been shown to significantly protect celiac patients from the serious symptoms they would normally experience after gluten ingestion. There are other enzymes, including those based on papaya enzymes.

    Additionally, there are many celiac disease drugs, enzymes, and therapies in various stages of development by pharmaceutical companies, including at least one vaccine that has received financial backing. At some point in the not too distant future there will likely be new treatments available for those who seek an alternative to a lifelong gluten-free diet. 

    For now though, there are no products on the market that can take the place of a gluten-free diet. Any enzyme or other treatment for celiac disease is intended to be used in conjunction with a gluten-free diet, not as a replacement.

    ASSOCIATED DISEASES
    The most common disorders associated with celiac disease are thyroid disease and Type 1 Diabetes, however, celiac disease is associated with many other conditions, including but not limited to the following autoimmune conditions:
    Type 1 Diabetes Mellitus: 2.4-16.4% Multiple Sclerosis (MS): 11% Hashimoto’s thyroiditis: 4-6% Autoimmune hepatitis: 6-15% Addison disease: 6% Arthritis: 1.5-7.5% Sjögren’s syndrome: 2-15% Idiopathic dilated cardiomyopathy: 5.7% IgA Nephropathy (Berger’s Disease): 3.6% Other celiac co-morditities include:
    Crohn’s Disease; Inflammatory Bowel Disease Chronic Pancreatitis Down Syndrome Irritable Bowel Syndrome (IBS) Lupus Multiple Sclerosis Primary Biliary Cirrhosis Primary Sclerosing Cholangitis Psoriasis Rheumatoid Arthritis Scleroderma Turner Syndrome Ulcerative Colitis; Inflammatory Bowel Disease Williams Syndrome Cancers:
    Non-Hodgkin lymphoma (intestinal and extra-intestinal, T- and B-cell types) Small intestinal adenocarcinoma Esophageal carcinoma Papillary thyroid cancer Melanoma CELIAC DISEASE REFERENCES:
    Celiac Disease Center, Columbia University
    Gluten Intolerance Group
    National Institutes of Health
    U.S. National Library of Medicine
    Mayo Clinic
    University of Chicago Celiac Disease Center