Celiac.com 01/25/2020 - Depending on what source you read, there may be as many as 6.5 million celiac patients in the U.S.  With these numbers, I have long believed that we really need to either find a cure or an effective way to manage this disease.  I, like many others, have been wondering if a "magic pill" would ever be produced so I could escape from the dry, terrible tasting, overpriced gluten-free food.  

Thus, when I read an article about some research being done on celiac disease, I contacted the company conducting the clinical trials so I could be placed on their mailing list and hear about the results as soon as possible.  At the time, I was not eligible to participate. 

To my surprise, a few months later, I was contacted by the agency conducting these trials.  They asked if I would like to participate in the next testing phase of a medication called Larazotide which was being produced by Alba Pharmaceuticals.  

Prior to this opportunity, my only contribution to the celiac community was my list of foods that were actually palatable, and which I sent to newly diagnosed celiac sufferers on request.  I also talked to my local specialty stores to ask them to order certain brands of foods and discontinue a certain brand of baked good that tastes like sand. 

With the invitation to be involved in this research, I now felt that I had an opportunity to really weigh in on a potential cure for this disease and really make a difference.  

At the appointed time, I went in for my physical and briefing. After learning about the drug, the study, and what would be expected, I signed on. I took my meds as instructed and kept my bowel movement data on what was affectionately named my "Brown Berry". This device was supplied by the agency as well as follow up visits and what I considered the most important benefit, both a pre and post-study duodenal biopsy.

I entered the program with some apprehension, but to my surprise, it went quite smoothly.  Appointments were made at my convenience and the contract allowed participants to leave the study at any time. The physical examination and subsequent follow ups were thorough and I was made to feel like a valuable part of the study.

This article is not a promotional piece for Alba Pharmaceuticals. I had not even heard of them until I got involved in the study. It is however, a promotional piece is for all of you reading this is to become or stay active in the celiac community. I know from experience that involvement in such activities encourages you to take an active interest in your health.  Whether it’s speaking to store managers about carrying quality products to make your life a little easier or getting involved in a study, it is time to be proactive. Don’t wait for someone else to step up. 

When this study is published sometime around the first of the year, I will be very proud of my small contribution. Let’s hope Larazotide is our "magic pill" and we can start enjoying real food again. Until then, please step up to the plate and become proactive in our health.  We all benefit from each others’ contributions.

Celiac.com 01/23/2020 - Researchers at the University of Maryland, under Alessio Fasano, have, once more, expanded the boundaries of human knowledge.  The implications of their most recent discovery may soon unlock the mysteries of several autoimmune conditions including celiac disease, inflammatory bowel disease, type 1 diabetes, multiple sclerosis, and some types of cancers.  Their discovery and subsequent report of zonulin, in 2000, was an enormous step forward.  It provided insight into one, perhaps the only, common mechanism that causes leaky gut.  Until then, many theories about leaky gut were proffered but none could be substantiated.  We only knew that some autoimmune diseases, bowel diseases, and food allergies (or delayed sensitivities as some call them) seemed to trigger a leaky gut.  Many of those with food allergies seemed to get some relief from eliminating foods to which their immune systems reacted, but we really did not understand the process by which these allergenic substances and various diseases induced a leaky gut.  

However, with the discovery and subsequent characterization of zonulin, it quickly became clear that a leaky gut was an important precursor to the development of at least some forms of autoimmunity. Although many medical practitioners continue to express skepticism about the importance of a leaky gut, emerging research findings should soon quell their concerns.  

Subsequent pharmacological research by Alba Therapeutics suggests that we may soon be able to abolish the permeable intestine that underlies so many autoimmune and other debilitating conditions.  Currently in clinical trials, Alba Therapeutics is finding that Larazotide Acetate (formerly AT 1001) is abolishing the inflammatory sequelae when individuals with celiac disease consume gluten.  

Healthy digestion involves absorption of tiny, digested particles into the epithelial cells that line the intestine.  These particles are then passed out the other side of the cell and into the bloodstream. These cells line the gut and maintain tight junctions to provide a protective barrier, except when zonulin attaches at cellular receptors. That is when the cells move further apart, allowing larger, undigested molecules to bypass the epithelial cells.  

Larazotide is designed to capture excess zonulin, which is over-produced by genetically susceptible individuals in response to ingested gluten.  This drug is designed to capture the excess zonulin proteins and waste them in fecal matter, rather than allowing them to attach at receptors on epithelial cells.  It is by this means that Larazodide is designed to prevent the development of a leaky gut, regardless of the cause of excessive zonulin production.  

Readers familiar with my work will not be surprised to learn that I’m not planning on eating gluten anytime soon.  But I’d sure like to be able to take a pill containing an otherwise harmless substance, when dining out, whether at restaurants or at friends’ homes.  I’d also like a tool that will help me to identify any other foods against which I may be mounting an inflammatory immune response.  

I imagine getting up in the morning and eating a couple of pancakes made from bean flours that I’m currently not able to tolerate.  If I take some Larazotide first, and I get through the morning without my typical reactions–bloated stomach and heartburn–then I’ll know both what the culprit is and what I can do if I really want to have a couple of bean flour pancakes one morning. 

Similarly (and much more importantly) it will provide people with a tool for helping them to determine whether they are experiencing symptoms of food allergies or if their discomfort is caused by something else.  For instance, if someone is unsure whether their foggy thinking really is the result of eating gluten, they can try Larazotide for a couple of meals.  If their foggy brain clears up, but returns when they stop Larazotide and eat a meal containing gluten, then they will know that food (probably gluten) is likely the culprit.  They may wish to pursue further self-testing or laboratory testing to identify specific problematic foods.

This drug may also provide a tool for investigating children with attention deficit disorders (ADHD). If food sensitivities are the underlying culprit, these children should behave and pay attention fairly normally after a period of taking Larazotide before they consume any foods.  We currently have no idea just how long such an intervention might take, but I’m hoping that researchers will soon answer such questions.  

I recently attended a conference on Crohn’s and colitis.  When talking about treatments, the primary issues under discussion were the impact of various drugs on individuals present.  The patients present shared a wealth of pharmaceutical knowledge.  There was also considerable discussion of research aimed at a cure.  In fact, the hosting organization seems quite fixated on finding a cure in the very near future. What a boon it would be, for everyone concerned, if Larazotide turns out to be that cure!

But we knew all of this before.  In fact, I’ve detailed most of this information in previous issues.  What is new, and intensely exciting, is that the research group at U.  Maryland has now determined that zonulin not only functions to increase intestinal permeability and inflammation, it is also a precursor to haptoglobin 2, a marker of inflammation  that is exclusive to human beings.  No other primates produce this protein, and only 80% of humans produce it.  Considerable research has connected sub-groups of this marker to a variety of cardiovascular diseases, a range of autoimmune conditions, and many cancers.  

Thus, the production of zonulin, which will ultimately mature into haptoglobin 2, is a feature of many more ailments than was previously imagined.  Since Larazotide is designed to capture and waste zonulin in fecal matter, we will soon be able to see what impact this drug can have on a variety of autoimmune diseases–and it promises to offer a tremendous benefit by halting the leakage of undigested proteins into the bloodstream that may be triggering autoimmune reactions by a process known as molecular mimicry.  

But that isn’t all Larazotide might offer.  It could also offer insight into what has been characterized as the plague of the Twentieth Century, cancer.  These inflammatory markers, haptaglobin 2, are elevated in association with many cancers.  If the inflammation proves to be a significant factor in the survival of tumors, we will be able to block its production and deny this substance to the cancerous tissues.  If, on the other hand, these inflammatory markers help the immune system to destroy tumors, we know how to trigger its production (in 80% of humans) and autoimmunity can be deterred by intravenous feeding during treatment.  Either way, there is genuine cause for hope.  

My money is on the former possibility.  I suspect removal of excess zonulin will reduce malignancies, but that is because diet can play an enormous role in cancer.  There is already considerable anecdotal evidence suggesting a ketogenic diet is a viable therapy for insulin sensitive cancers.  Time magazine ran a feature article titled “Can a High Fat Diet Beat Cancer?” in their September 17, 2007 issue.  (The greatest difficulty these researchers are encountering with these trials is dietary compliance. Another serious problem is that their ethical approval required that all conventional treatments be exhausted before beginning the dietary trial.  Thus, many of their research subjects are very sick before they begin the diet.  For these reasons, one of the universities has stopped running these trials despite some promising preliminary results.) Whichever way it goes, Larazotide may well lead to some dramatic advances in cancer research in the very near future.  

Larazotide may also help some type 1 diabetics turn back the clock.  Those who undergo islet cell transplants can usually only expect a year or two of reduced insulin requirements before they return to their former status.  Larazotide may be able to halt the autoimmune destruction of the islet cells which produce insulin, allowing individuals who undergo transplants to experience relatively normal lives, without worrying about balancing the size of their insulin injections with their carbohydrate intake.  They may well be able to forego injections entirely for the rest of their lives.  

Individuals with various autoimmune diseases may be able to halt the progression of their illness and return to more normal lives.  Those with multiple sclerosis, Crohn’s disease, some forms of arthritis, lupus, and a host of other ailments may be stopped in their tracks.  There may even be hope that people like me, with chronic lung disease, will be able to begin rebuilding healthy lung tissues.  Reduced haptoglobin 2 may result in reductions in inflammatory reactions to airborne allergens.  This, in turn, may permit us to breathe well enough that we can exercise and build healthy lung tissues without scar tissues.  I’m not suggesting that we will be able to return to our 25 year-old activities, but I believe we may be able to live more normal, more productive lives for whatever time we have left.  

Finally, Larazotide may even bring about reductions in the excess mortality found in the celiac disease and gluten sensitive community.  We have a lot to be grateful for. The research group directed by Alessio Fasano is making enormous contributions to broadening medical understanding of celiac disease, expanding medical knowledge of autoimmunity and cancer, and increasing celiac awareness (see:  Scientific American, August 2008, “Surprises from Celiac Disease” by Alessio Fasano). As I said at the beginning, “They’ve done it again!”

Celiac.com 01/11/2020 - Life used to be so much simpler. Fifteen years ago, when a celiac used an “alternative flour mixture”, it meant sifting together white rice flour, potato starch, and tapioca flour. The kitchen got dusted with flour as you sifted the blend together, but you never had more than three different kinds of flour to store. Today, the alternative flour choices are almost endless… and confusing. 

There is no one alternative flour that can duplicate the properties found in wheat flour.  That’s why it’s necessary to combine different flours together. Each one has its own unique properties. When you better understand what each flour contributes to a mix, it makes it easier to decide which flours to use.

Just to confuse things a bit more, different flour mixtures are better for different baked goods. While sorghum flour is excellent to use when making bread dough, cornstarch can work well for some cookies. Nut flours add flavor and fiber, but millet is easier to digest. 

The easiest way around all this is to come up with one flour mixture that works well for you. Measure, sift together, and store it in a self-seal bag in the freezer (so it doesn’t get rancid) and it’s ready to use when you get the urge to bake. Then, if your recipe calls for 2 cups of flour mixture, use 1 ½ cups instead and substitute the other half cup with sorghum flour when making bread, or with cornstarch when making cookies. 

Do you remember how easy it used to be to open up a bag of wheat flour, spoon it into a canister, then set the canister on your kitchen counter and leave it for a year, using the flour as needed?  Unfortunately, many of the alternative flours will turn rancid after a couple of months at room temperature. This change won’t be noticeable, but your baked products just won’t taste the same… or as good. The alternative flours do not freeze to a solid state, so blend your mixture, and then keep it in the freezer to prolong its life.

Understand that spelt is NOT gluten-free. Many people who work in health food stores are very aware of this, but some are not. Occasionally you will even find some stores selling spelt bread in the gluten-free section. As a celiac, you need to be aware of what you can and cannot consume.

Flour settles and compacts when it is stored. Before measuring flour for a recipe, whisk it to aerate it, then lightly spoon the mixture into a measuring cup. Don’t use the measuring cup as a scoop because you can get between 10% to 20% more flour that way, and that will definitely affect the moistness of the finished baked product.

Duplicating the taste and texture of wheat flour is possible, though challenging. Wheat flour has gluten which creates elasticity. Lack of gluten can lead to a heavy, dense texture… but not necessarily. If you choose the right alternative flours and play a few tricks with the dough, you can create a baked product that is every bit as tasty, light, and airy as any gluten product.

Let’s examine what each of the different flours adds to dough, starting with the basic rice flour. White rice flour has a sweet, very mild taste, but negligible nutritional value. If you use this flour, try to use the most finely-ground brand you can find to avoid a gritty taste. Asian markets often carry finely-ground rice flour. Brown rice flour still has the bran layer intact so it’s higher in B vitamins, iron, and fiber. Both rice flours tend to be dry so it’s best to combine them with flours that help retain moisture.

The next two most common flours used are potato starch (not to be confused with the thickener potato flour) and tapioca flour. Both are white and both have a very unique feel to the flour. Potato starch adds moisture and chewiness, which makes it perfect for cookies, and it can tolerate high temperatures. The moisture in potato starch helps to balance the dryness in rice flour. Tapioca flour (or tapioca starch) is made from the dried starch of the cassava root. It is mildly sweet and helps baked goods to brown and to have a crisp texture. This flour thickens when it is heated with a liquid, making it the perfect choice for thickening puddings and fruit pie fillings.

The varieties of bean flour available are increasing constantly. Originally, there was fava bean flour, garbanzo bean (or chi chi bean) flour, or a combination of the two called garfava flour. Now you can find lentil flour, mung bean flour, pea flour, black bean flour, white bean flour, mesquite bean flour… and the list goes on. Beans are high in fiber and high in carbohydrates (the good kind of carbs). The flour retains moisture, giving baked goods a lighter texture. Be careful not to use too much bean flour as it can give baked goods a metallic taste and can definitely contribute to flatulence.

Nut flours have become very popular because they add both nutrition and flavor to baked goods. They are high in protein, low in carbs, and add a wonderful crunchy texture. They cook more quickly and are more likely to burn when used alone, so it’s best to combine the nut flours with the traditional gluten-free flour mixture. Almond flour (or almond meal) adds moisture and flavor. Cashew flour and chestnut flour both have a toasty, slightly sweet taste. Hazelnut flour adds moisture and flavor. And pistachio flour is a wonderful choice when making desserts. Coconut is actually a nut from the palm family. Coconut flour adds a delicious taste and is very high in fiber. When using this flour, add a little extra liquid because coconut flour will absorb more moisture than most flours.

Sorghum flour is fairly new to the limelight. It is made from sorghum berries and has a light, sweet, nutty flavor. The beauty of using this flour is that it adds an ‘almost-like-real-wheat’ texture to breads. 

Then there are the flours that have more nutritional value than rice/potato/tapioca flours. Amaranth is high in both fiber and protein. It has a sweet flavor but the flour retains a lot of moisture. If you opt to use this flour, use about 2 teaspoons per cup of traditional flour mixture. Buckwheat flour comes from an herbal plant that is related to rhubarb. While it has fiber and nutrients, it has a strong, musty flavor that may take some getting used to. It also absorbs oil so you may need to add more oil to your batter to get the right consistency. Corn flour or cornmeal can be another addition to breads and muffins because of its slightly sweet flavor that will cover up any aftertaste from the rice flour mixture. If you are using a corn-based flour, it is worth paying a bit more to get very finely ground flour; the degree of ‘fineness’ will determine if the finished product is gritty or smooth tasting.

Other flours that offer more fiber and nutrients include oat flour (made from uncontaminated oats). Oat flour has the second highest protein content of any grain flour. Sweet potato flour is now sold on amazon.com and is high in nutrients. Soy flour has become more widely used, though it has a slightly bitter flavor. It is low in carbs and browns very easily, so use it sparingly in addition to a regular gluten-free flour mixture. Teff flour also falls into the ‘more nutritious’ category. It is available in natural brown (stronger taste) and ivory (milder taste) varieties. It has a mild, nutty flavor, and adds moistness to batter (so it’s good to use this flour in combination with flours that absorb moisture). Teff has the highest calcium content of any grain flour. Quinoa (pronounced keen-wa) flour is gaining in popularity. The nutty flavor can be almost overpowering when used alone, but when combined with other flours, it helps to retain the moisture. Quinoa flakes often work better than using the flour when baking.  Finally, in the category of more nutrients and more fiber, there is flaxseed meal. Whether you buy the dark meal which has a bolder nutty taste, or the golden meal which is so mild it is almost tasteless, you will be getting a product high in Omega-3 fatty acids, very high in soluble fiber and lignans, plus the added benefit that flax (like eggs) help gluten-free baked goods to be lighter in texture.

Arrowroot flour and millet flour are both high in fiber. Their forte is that they are both very mild on the stomach. If you are making teething biscuits for a baby or a baked good for an adult who has trouble digesting food, these two flours are excellent choices. Millet is the least allergenic of all of the alternative flours. It has a slightly sweet, buttery taste, but the surface of a product made with millet tends to dry out more than when it is used in combination with other flours are used.

One of the major complaints about gluten-free flour mixtures is their lack of fiber. I have created my own high fiber gluten-free flour mixture and have used it to bake everything from bread to cookies and cakes, to pie crusts and cream puffs. To the best of my knowledge, it has more fiber and more nutrition than any other flour mixture… and far more taste. If the recipe you are using lists xanthan gum as an ingredient, you will not need to add it since the recipe below already includes the xanthan gum.

High Fiber Gluten-free Flour Mixture

This mixture has 4.12 grams of fiber per 1/4 cup flour mixture.

Ingredients:

• 2-1/2 cups brown rice flour
• 1-1/2 cups sorghum flour
• 1 cup potato starch 
• 1 cup tapioca flour
• 1 cup coconut flour
• 3/4 cup garbanzo bean flour
• 2/3 cup golden flaxseed meal
• 1/4 cup cornstarch
• 3 tablespoons xanthan gum

Directions:
Yield:  7-3/4 cups
Sift all the ingredients into a bowl, then whisk the ingredients with a wire whisk to assure that everything is blended evenly.

Per 1/4 cup—Calories: 142; Total fat: 1.6 g; Saturated fat: 0.2 g; Cholesterol: 0 mg; Sodium: 1 mg; Carbohydrates: 29.1 g; Fiber: 4.12 g; Sugar: .08 g; Protein: 2.9 g.

Celiac.com 01/04/2020 - My interest in quality of life and celiac disease originated 4 years ago, beginning with my own diagnosis of celiac disease. I was relieved to finally have an accurate diagnosis after almost 15 years of misdiagnosis by an internist. He was convinced that my lack of energy was due to depression, but another physician, who suspected celiac disease, ran some tests and found that my lack of energy was due to limited absorption of nutrients.

My psychological and subsequent physical relief over the diagnosis soon turned to frustration. I realized that I needed to adhere to a strict gluten-free diet. To my dismay, I found that many products contained gluten since it is an inexpensive binding agent. I also found it was necessary to be cautious about a variety of food products, vitamins, medications, toothpaste, lipstick and even postage stamps.

I initially thought "Why wasn't I taught any of this in my nursing program?" There was a lot of information on diabetic diets but virtually nothing on the gluten-free diet. Of course, I also remembered that the teachers taught us that celiac disease only occurs in children. Being a nursing professor, I was also alarmed at how little my colleagues knew about celiac disease and the gluten free diet.

After a lot of reading about celiac disease I realized how common it is for physicians to misdiagnose it. Adult celiac disease is not emphasized in medical, nursing or other allied health educational programs. I guess I should forgive my internist!

I decided to educate every doctor, nurse, student, and anyone else who would listen. I am sure that people whispered "Here comes the celiac advocate again." Educating health professionals was interesting. In fact, one nurse said to me that she could never be on a gluten-free diet.

I said to her "Like one has a choice".

In addition, my life as a social butterfly was undergoing a metamorphosis. My pre-celiac diagnosis life consisted of social interaction with friends and associates at restaurants, parties and other social events. My husband and I also enjoyed eating out at good restaurants. In addition, I love world travel and sampling various ethnic foods.

Passage:

"Is this GF diet a conspiracy to ruin my life?"

Compulsive grocery shopping

I began to see life as having dealt me a nasty card. I do not enjoy grocery stores and I previously spent as little time as necessary shopping for food. I used the get in–get out approach. I rarely looked at food ingredients. Grocery shopping was just a means to an end.

Now I must compulsively check ingredients for any hint of gluten. It has become the enemy and it is secretly hiding everywhere. And it's not just in the grocery stores. In some restaurants waiters told me that there was no gluten in the food, then arrived with a dish crusted in bread crumbs. I especially enjoyed the time when a waitress said that we do not use wheat in this dish and came out with a flour tortilla.

I once interviewed a Chef who told me that she was on a gluten-free diet for one year. She said that it was the most frustrating experience of her life. She said that gluten forms the cohesive basis for most foods. It was what made baked goods nice light and fluffy. She was glad that she no longer had to be on the diet.

Oh yes! Did I tell you that I have a shelf filled with many gluten-free cookbooks? They are busy collecting dust. Good intentions but not one has been opened yet. This is, in part, due to my workaholic schedule but the rest you can attribute to my lack of motivation.

Health Food Stores and Gluten-free products

Thank goodness for the celiac support groups. The group in my area has been so active and has encouraged the local health food stores to carry a lot more gluten-free products. To my surprise they sell GF fresh baked goods and other groceries. I was thrilled! However, I also started realizing that these products were often more expensive and some of the baked goods were very dense with calories compared to those that contain gluten. I was consuming a lot more calories than I should eat.

Weight gain

The next problem was gaining weight. Being able to absorb nutrients now, and the high caloric content of much of the GF products, caused me to gain weight. I decided to search for weight loss programs that could accommodate a gluten-free diet. Programs such as Jennie Craig do not accommodate GF diets. I finally found an expensive weight loss program that provided a nutrionist to develop a customized program. As with other things in my life, the program closed seven months later.

Passage: Perceiving the glass is half -full

Being on a Gluten-free diet has had some positive outcomes.

Eating healthy and friends

Shopping in health food stores has made me eat healthier than I have ever eaten in my life. My social life is diminished but I have some really good friends who consciously try to provide gluten free food for me. Others view it as though it is a preference on my part saying: "You can have a little gluten." I now know who my real friends are.

Making new friends

I was on a movie set a couple of months ago and a well known actor was there. I found out that he has celiac disease. It was like meeting an old friend. We talked for over an hour about gluten free diets, and the impact it has had on both our lives. You see, being a celiac helps you make new friends!

A New focus for my life's work

Being a celiac has also provided a new focus for my research. I am trying to help better understand the quality of life issues for those of us with celiac disease. I feel like I have this "inside" perspective.

In conclusion

Someone asked me the other day "If you had a week to have whatever you want, what would you choose?" I surprised myself by saying "To eat regular food for one week. That would be my dream."

She laughed. Then she realized that I was serious. Maybe I haven't come as far in my passages as I thought.

Celiac.com 01/02/2020 - Osteoporosis is the 11th leading cause of death. 1 in 2 women and 1 in 4 men is affected.  

We sometimes think of our bones like the walls in a room - they hold things up but we consider them rather inert.  On the contrary, our bones are very much alive, constantly remodeling themselves by getting rid of old bone cells and rebuilding with new bone cells.  Further, healthy bones are needed for immune function since all our red and white blood cells are made in the marrow of our bones.

There are some drugs available to “treat” osteoporosis but they are laden with side effects.  Some are even cancerous.

In Nutrition Reviews 2007, a study report titled “Osteoporosis and Inflammation” revealed that inflammation triggers the shift from healthy bones to
osteoporosis.

So let’s look at how osteoporosis is related to digestive function.  A recent article in Cell 2008 entitled “When the Gut Talks to Bone” revealed that certain genes (Wnt genes) trigger signaling factors required for the development of bones and nerve structures within the body. What was most interesting was the revelation that these genes are activated by serotonin.  Where is the vast majority of serotonin made?  In the gut!

We have previously seen correlations between the brain and the gut, such as in chronic IBS which is strongly correlated to stress. But gut serotonin actually “talks” to our bone, thereby creating a strong connection between gut health and bone Health. This is quite new in the research. It substantiates something I’ve seen in my patients for years.

The more inflammation is present, the more the gut makes serotonin which in turn leads to bone breakdown – osteoporosis.

What does all this mean?  It means that lowering inflammation in the body is critical in the prevention of osteoporosis (not to mention heart disease and cancer but we’ll leave those connections for another article.)

How do we lower inflammation?  One of the biggest inflammation inducing culprits is gluten. It not only creates local inflammation in the gut but it creates systemic inflammation through its affects on the immune system in sensitive individuals. And remember, current research considers 40% of the population to be gluten sensitive.

In the New England Journal of Medicine 2007 it stated that celiac disease inflamed the gut, thereby creating bone loss.  

The good news in all of this is that reducing inflammation is something we have control over. We can find out if we’re among the 40% of the population that is gluten intolerant. We can change our diets.  We can use supplements such as omega-3 fatty acids to reduce inflammation and help heal the lining of our intestines. These tools are within our reach.  Further, remember that gluten reduces absorption of certain key vitamins and minerals such as calcium and Vitamin D, which are critical to bone health. Have your Vitamin D level evaluated and supplement as needed.

Osteoporosis is a very debilitating disease. Now we know it doesn’t have to be.

Celiac.com 02/27/2015 - The answer to the "oats questions" are becoming clearer.

The long-asked question is "Can people with celiac disease or gluten sensitivity safely eat oats?" Some people are so sensitive, that even the tiniest bit of gluten makes them feel unwell. So this answer is important because people on a gluten-free diet should not restrict foods unnecessarily. There are several aspects to this question:

1. 1. Avenin: Oats do not naturally contain gluten ... but there is a similar protein called "avenin" found in oats that has the same properties as gluten (it is the "prolamine storage protein" of oat seeds, that helps protect the dormant seed and nourish it when it begins to grow).

   Fortunately, adverse reactions to this oat protein are rare. A study of 10 pertinent studies, with a total of 165 patients, found only 1 patient who had histological gut damage as a result of eating oats. This condition is now called "avenin-sensitive enteropathy" (ASE). This is documented by Garsed & Scott "Can oats be taken in a gluten-free diet? A systematic review" (Scand. J. Gastroenterol. 2007:42: 171–8.

   Clinical reports now provide strong evidence that oats very rarely cause damage to the gut mucosa in people with celiac disease. Subsequently, guidelines from many coeliac societies now reflect this new evidence. Moderate amounts of oats (half a cup of oats a day) can be consumed by most celiacs without risk of damaging intestinal villi. However, it is important to emphasise that these oats must be free of other contaminating gluten-cereals.

   What is not reported is whether some of these people experience symptoms (feel unwell) despite the healthy appearance of their gut under a microscope. These people might have an "avenin-sensitivity" similar to gluten-sensitivity without any accompanying gut damage. This question has not yet been investigated.
    

2. Cross-contamination: The reason that many people apparently react to oats is not because of the avenin, but to inadvertent gluten contamination. In other words, wheat and other gluten-grains accidentally get into the oats.

   Traces of gluten are commonly found in packets of oats–this is from the cross-contamination of oats with other gluten-grains. This contamination can occur during any stage of the life-cycle of oat production: the planting, the harvesting, the transportation, the processing and the refining of oats. It is almost impossible to avoid such cross-contamination unless all this machinery is exclusively devoted to oats production. This requires large-scale production as is seen in the USA.

   One research group analyzed a total of 134 oats samples, comprising grains and commercial oat products collected from Europe, the United States and Canada. This study confirmed that most oats were contaminated with mixtures of wheat, barley and rye (Hernando et al. "Measurement of wheat gluten and barley hordeins in contaminated oats from Europe, the United States and Canada by Sandwich R5 ELISA". Eur J Gastroenterol Hepatol. 2008 Jun;20:545-54.)
    

3. Level of gluten sensitivity: How intensely people react to gluten varies. Some people can eat moderate amounts of gluten and have no symptoms at all. Whilst many are so sensitive that even the tiniest amount upsets them. Thus, minimal cross-contamination of oats with gluten is a problem for a significant proportion of the gluten-sensitive community.

   It may be that people who have extreme gluten sensitivity are more likely to react to avenin. It is my observation that super-sensitive gluten reactors seldom tolerate oats. However, this subject has not been researched.
    

4. Asymptomatic gluten damage: Oddly, some people can have the gut damage of celiac disease without experiencing noticeable symptoms. They have severe gut damage but are completely unaware of it. Such a diagnosis is usually discovered by screening blood test. As these people do not get any symptoms from gluten, they would not know if oats are upsetting them either! These asymptomatic celiacs need to be followed up with regular blood tests (and perhaps subsequent biopsy) to ensure that they are healing.
    
5. Why bother with oats?

   The ability to use oats in your diet gives an important source of fibre as well as other important nutrients. They have a low glycemic index (GI) which makes them satisfying to eat. Also, eating oats will contribute to lower cholesterol levels. And of course, it gives you a valuable additional food to make the topping on apple-crumble, hot oat porridge on a cold morning, and a crunchy, tasty muesli.

   Some companies certify their oats to be gluten-free, which means they are free from any cross-contamination. If you are very sensitive to gluten, then you might not tolerate oats. The best thing to do is try a little and see.
    

6. Do blood tests: "Get a blood test!" is my mantra. So many people go gluten-free without a blood test. So many people with celiac disease never get follow-up blood tests. It is important to get a firm diagnosis of celiac disease / gluten sensitivity. Then to get more tests a year or two later to make sure that your body is healing. One way to check out how you are tolerating oats in your body is to get regular blood test checks for gluten (IgG-gliadin) and for tissue damage (DGP/tTG)–for more details please visit me at my website.

Celiac.com 12/11/2009 - I recently embarked on a quest for family-friendly restaurants that offered gluten-free selections.  I explained this vision to my husband and three children as we set the rules of our experiment: five family members to eat at five restaurants during a five week period.  The challenge - the children were to choose the restaurant, the chosen restaurant couldn’t sell Happy Meals or have a drive-thru window and the restaurant had to be a franchise rather than a local venue.  Additionally, the mom, me, and the only celiac in the family, had the option of not eating if it might compromise her small intestines.  Here is what we discovered:

Restaurant # 1: Applebee’s
My children chose to eat at Applebee’s on a Sunday afternoon for lunch.  The atmosphere was friendly and a plentiful kids’ menu was offered.  With over 1900 restaurants nationwide and in 15 other countries, according to the company website, it seems there is an Applebee’s almost everywhere.  Additionally, Applebee’s offers a Weight Watcher’s menu for restaurant patrons who are counting points, which led me to hope an allergy/gluten-free menu would also be provided.

After we were seated, I perused the menu to read this statement, “To our guests with food sensitivities or allergies.  Applebee’s cannot ensure that menu items do not contain ingredients that might cause an allergic reaction.  Please consider this when ordering.”

I spoke to a manager and asked if a gluten-free menu was available.  I was informed, “Applebee’s policy is not to guarantee allergy-free food.  Our company does not carry a gluten-free menu, but we can modify food.  For example, we can prepare grilled chicken breast strips for kids, rather than giving them breaded chicken fingers.  Again, we don’t guarantee the food will not come in contact with the allergen.”

Restaurant #2: Red Robin
The next stop on our restaurant expedition was Red Robin, which also offers an extensive children’s menu.  According to the company website, there are over 430 Red Robin restaurants, in North America.  After we were seated in our booth, I asked our server if a gluten-free menu was available.  She immediately went to the kitchen and returned with a printed Wheat/Gluten Allergen menu.  Printed on the top of the menu was the statement, “Red Robin relied on our suppliers’ statements of ingredients in deciding which products did not contain certain allergens.  Suppliers may change the ingredients in their products or the way they prepare their products, so please check this list to make sure that the menu item you like still meets your dietary requirements.  Red Robin cannot guarantee that any menu item will be prepared completely free of the allergen in question.”

Gluten-free offerings were grouped in the following categories: salads; salad dressings; burgers; chicken burgers; entrees; and available side dishes.  The Kids’ menu offered a beef patty burger, turkey patty, and chicken-on-a-stick.  It stated: “Kids may also select from any items listed on the Wheat/Gluten menu as adult items to custom design a wheat/gluten free meal for your child.  This menu is current and valid until 10/1/09.”

I was informed by our server that when a customer orders from the gluten-free menu, an allergy alert is put on their ticket and the area of food preparation is cleaned to avoid cross-contamination.  Additionally, the fries are prepared in oil specifically designated for fries, and those with a gluten allergy should avoid the fry seasoning.

I ordered off of the Red Robin gluten-free menu and personally recommend the Crispy Chicken Tender Salad with grilled chicken rather than crispy, no garlic bread, and the honey mustard dressing.

Restaurant #3: Garlic Jim’s Famous Gourmet Pizza
It was a Friday evening and my children decided they really wanted to eat pizza for dinner.  This led us to almost break our fast food rule by ordering carryout from a pizza restaurant.  Ordering pizza is an extreme challenge for those suffering from gluten intolerance. Therefore, I had to do my research ahead of time.  I called Papa John’s, Domino’s, Papa Murphy’s and Pizza Hut to confirm that gluten-free pizza is not offered, at any of these pizza chains.  I did find a pizza franchise in my state, called Garlic Jim’s, which offers a gluten-free crust. 

According to the chain website, “Garlic Jim’s is proud to be the first pizza chain accredited for gluten free food service by the Gluten Intolerance Group of North America.”  Garlic Jim’s Famous Gourmet Pizza is currently located in seven states including; Washington, Oregon, California, Idaho, Colorado, Tennessee, and Florida.

I was informed at the restaurant that the gluten-free crust is covered with sauce in a separate area in order to avoid cross contamination although the toppings are put on in the same location where wheat-based crusts are prepared.  Different pans and utensils are used in the preparation of this gluten-free thin crust which costs three dollars more than their traditional pizzas.  The restaurant also posts a sign stating that although they do offer gluten-free pizza, they cannot guarantee the pizza will not come in contact with allergens.

I recommend the gluten-free pepperoni pizza, and can attest that pizza has never tasted so good.

Restaurant #4:  The Old Spaghetti Factory
The Old Spaghetti Factory was established in 1969, and as of today, boasts 39 locations nationwide.  I was quite pleased to discover, when my children chose to eat at The Old Spaghetti Factory, that they offer gluten-free pasta.  Before being seated, I inquired at the hostess desk if a gluten-free menu was available and I was presented with a laminated copy. 

Each entré includes complimentary salad, bread, and ice cream. Obviously, those with gluten intolerance need to give the bread a pass, but there are viable options available for the remainder of the meal.  Gluten-free salad dressings include pesto and vinaigrette—hold the croutons on the salad.  The main course is a rice pasta with the following sauce choices: marinara; meat; mushroom; mizithra cheese, and; brown butter.  Diners also have the option of adding gluten-free sausage and sliced chicken breast to their meal.  For dessert, a choice of spumoni or vanilla ice cream is offered. 

 I ordered the Manager’s Favorite pasta, which includes a combination of two sauces.  I chose gluten-free pasta topped with marinara sauce and mizithra cheese.  My dinner also included a salad with vinaigrette dressing and spumoni for dessert. 

Restaurant #5: Outback Steakhouse
Our final dining choice was the Outback Steakhouse which, according to the company’s website, is an Australian Steakhouse with over 950 locations worldwide.  I was offered a gluten-free menu that is nearly as large as the main menu.  Offerings included appetizers, steaks, chicken, seafood, salads, side dishes, and even a brownie dessert.  The entire gluten-free menu is available on the Outback Steakhouse website, www.outback.com .

Our server was very knowledgeable of gluten intolerance. I ordered off of the gluten-free menu.  When ordering salads, it is recommended that you request that they be mixed separately to avoid cross contamination.  Overall, it was a very pleasant dining experience for my entire family, with a plentiful menu for me and an ample kids’ menu.

I would certainly recommend what I ordered— Victoria’s Filet with a baked potato and a salad without croutons.  I passed on the bread which accompanies every meal.  It was a pleasant dining experience at what is quite possibly the restaurant that has set the current gold standard for gluten-free dining.

Overall, our experiment was a great success with four of the five restaurants we visited offering gluten-free menus.  I advise diners to be cautious wherever they eat because even if a company offers gluten-free options you must also take into account the knowledge of the chef preparing your food and the server assisting you.  It is encouraging that major restaurant chains are acknowledging the need to modify their menus for those suffering from gluten intolerance.  Good luck and happy dining.

In my view the same approach should be adopted for anaphylaxis inducing ingredients like peanuts, eggs, sesame seeds, shellfish and crustaceans: that it is best to exclude them entirely to eliminate the risk of accidental contamination. Any other approach requires extremely alert and well informed operators in combination with elaborate cleaning and testing protocols; all of which are prone to mistakes and failure.

It is my view, that many people are too cavalier in their approach to the matter of gluten contamination, taking the attitude that “a little won’t hurt.” Many manufacturers, particularly restaurants, small bakers and pizza makers etc., for example, are often asked about making gluten-free products and see this as a means of expanding their businesses. Something many of them attempt without properly trained staff and without fully understanding the implications and risks of undertaking such a project. However, there are also many worthy exceptions to this comment: the difficulty is in finding them.

In flour and bakery situations gluten is always present and is often used as an ingredient. Typical suburban bakeries tend to have flour and hence gluten everywhere. Flour and gluten are insidious and can float in the air for many hours after use and can be dislodged by banging doors and draughts. Benches, tins, trays, dough rollers, dough dividers, bread slicers, utensils, belt ovens etc., are often contaminated with gluten and many of these items are difficult to clean thoroughly. Bakeries are inherently difficult to keep clean and maintain in a gluten-free state.

Deep fryers are also fraught with difficulty. For example, potato chips which are gluten-free by definition, can easily be contaminated with gluten from the gluten residues left in the deep fryer by cooking such products as crumbed calamari, veal schnitzel, chicken schnitzel, spring rolls, battered fish and the like in the same deep fryer. The only way to produce gluten-free potato chips is by having and maintaining an exclusively gluten-free deep fryer where only gluten-free batters and crumbs etc., are used. Extreme care must also be taken with bench surfaces and all utensils, aprons, towels etc., used and in washing hands.

Other contentious areas are colorings, flavorings, salad dressings, thickeners, gravies, sauces, for both savory and dessert applications, as these often introduce gluten contamination to otherwise gluten-free meals and foods. If already applied to a meal these can never be fully removed by attempting to scrape them off. The meal should always be totally replaced with a sauce or whatever free meal or course.

In my view, the consumer’s safety and well being should always be paramount: the consumer should not be imposed upon and they should be given an informed choice as to what they consume at any time. This is the basis upon which we run our business. Avoidance of all the above problems requires well trained and aware staff working under well informed and aware management in a clean and well controlled environment.