The Good News!
In general, the South American diet contains less gluten than the typical western diet, with white rice and potatoes being the staple carbohydrates for most countries. So there will probably always be options on the menu that are naturally gluten-free. And if in doubt, you can always stick to simple dishes like grilled meat or fish, and fresh salads.

The Bad News…
Celiac disease and the gluten-free diet are much less common in South America, so although products in supermarkets may be labelled 'gluten-free' most people probably don't fully understand what this means. The language barrier can cause problems when enquiring about gluten-containing ingredients and cross-contamination. So it's advisable to learn or print out some useful phrases to help you explain your dietary requirements.

Eating Gluten-Free in Brazil

Labelling Laws: All packaged foods must be labelled either 'contén glúten' or 'não contén glúten'. You can use these phrases in restaurants too, although the serving staff may not really understand what this means.
Advice: English is widely spoken, especially in the major cities, so communicating your dietary requirements shouldn't be too difficult.

Naturally Gluten-Free Brazilian Foods:

• Tapioca/cassava flour – often used in place of wheat flour to thicken sauces. Tapioca pancakes are a popular breakfast food, and cassava fries are a popular snack, both of which are naturally gluten-free, but always check about cross-contamination.
• 'Pão de queijo' – These cheese balls are traditionally made using tapioca flour so are naturally gluten-free, but always check because in some hotels they'll contain wheat flour as well.
• BBQ meat – Brazil is famous for it's barbequed meats, which are not usually coated in flour.
• Top Dish: 'Moqueca' – This fish stew is cooked in a sauce of coconut milk, palm oil, parselt, garlic, tomato puree and peppers. These are the staple ingredients of many meals in the north of Brazil, which is a particularly good area for celiac travellers to visit.

Eating Gluten-Free in Peru

Labelling Laws: There are no laws in Peru which require products to be labelled 'gluten-free', and most people will not have come across celiac disease.
Advice: Lima is probably the best city to eat gluten-free, as it has some of the best restaurants in the world and very experienced, knowledgeable chefs. So use words like 'trigo' and 'cebada' to explain that you can't eat wheat and barley, and you should be understood. The main problem in Peru is fusion cuisines, like 'chifa', which are heavily influenced by Asian cooking and nearly always contain soy sauce. Wheat flour is often used to coat foods before frying in Peru, and is often used to thicken sauces, so ensure you know the basic Spanish phrases to explain your needs.

Naturally Gluten-Free Peruvian Foods:

• Quinoa – This is the staple grain in Peru, and you'll find soups and stews containing it everywhere.
• 'Tamales' – Corn flour is used to make this breakfast food or snack, which is steamed in a corn husk and filled with meat or cheese.
• 'Ceviche' – This popular dish has a very basic recipe of raw fish, citrus juices and seasoning, so it's always gluten-free.
• Top Dish: 'Rocoto Relleno' – This is a vegetarian dish of stuffed hot peppers.

Eating Gluten-Free in Argentina

Labelling Laws: Argentina has a law that requires packaged foods to be labelled 'sin TACC', if they are suitable for those on a gluten-free diet.
Advice: Many traditional dishes are naturally gluten-free, so you should find suitable meals on most restaurant menus. However the language barrier can be a problem in more rural areas. Buenos Aires is one of the best cities in South America for celiacs, as it has a few gluten-free restaurants and even a bakery.

Naturally Gluten-Free Argentinean Foods:

• Steak – Argentinean steaks are famous around the world, as are usually served with the dressing on the side, with salad or vegetables. Sometimes it's also served with fried potatoes or chips which you'll need to ensure are suitable.
• 'Fainá' – This flatbread is a popular snack, made from chickpea flour. It's naturally gluten-free, but always check that wheat flour hasn't been added as well.
• 'Asado' – Barbequed meats are also popular in Argentina, and should be naturally gluten-free.
• Top Dish: 'Humitas' - This snack is made from seasoned corn flour, boiled in a leaf or husk, very similar to Peruvian 'tamales'.

Eating Gluten-Free in Chile

Labelling Laws: Supermarkets may stock foods labelled as gluten-free, but these are mostly imported from nearby countries, such as Argentina.
Advice: Even snacks like crisps, chocolate and yoghurts may not be suitable for celiacs in Chile, so try to learn the Spanish words you'll need to make reading packaging easier. Similarly in restaurants, English may not be widely spoken and the concept of 'gluten-free' won't be fully understood.

Naturally Gluten-Free Chilean Foods:

• 'Milcaos' – This street food snack is naturally gluten-free, as it only contains mashed potato and raw, grated potato fried in oil. The only risk is cross-contamination from the oil.
• 'Pastel de Choclo' – This popular dish is a stew/pie of ground beef or chicken with olives and raisins. The crust is made from pureed corn, so it's naturally gluten-free.
• 'Paila Marina' – Seafood stews and soups like this are very popular and usually gluten-free, although bread is often served as an accompaniment.
• Top Dish: 'Caldillo de Congrio' – It's not for everyone, but this boiled eel stew is a Chilean favourite.

Eating Gluten-Free in Bolivia

Labelling Laws: There are no labelling laws in Bolivia, and you may struggle to find suitable snacks in supermarkets.
Advice: Bolivia is a tough country for celiac travellers, as English is not widely spoken and the term 'gluten-free' won't be understood by most people. You will need to learn Spanish phrases to help you get by.

Naturally Gluten-Free Bolivian Foods:

• 'Sonso' – This is a street food snack of yucca (similar to potato) and cheese, cooked over a BBQ.
• 'Pique Macho' – Bolivian's like sharing dishes, and this is a particular favourite, containing beef, hot dogs and boiled eggs, served with chips. You'll need to check that the chips haven't been cross-contaminated during frying.
• Quinoa – Similarly to Peru, quinoa is a staple grain in Bolivia, and you will find it in many soups.
• Top Dish: 'Palta Rellena' – This starter is typically Bolivian, an avocado stuffed with chicken and shrimp. It's very simple and naturally gluten-free.

Eating Gluten-Free in Ecuador

Labelling Laws: Similarly to Bolivia, you probably won't see 'gluten-free' labels in supermarkets.
Advice: Wheat doesn't feature heavily in traditional Ecuadorian cuisine, as yucca, plantain and rice and the preferred carbohydrates. But bread is served with nearly every meal, and in international restaurants wheat flour will probably be used, so opt for traditional-looking restaurants.

Naturally Gluten-Free Ecuadorian Foods:

• Plantain – This banana-type fruit is very popular is Ecuadorian cooking and can be served in many ways. 'Chifle' is a particularly popular plantain dish, dried and salted to taste.
• 'Pan de Yuca' – These cheese balls are very similar to the Brazilian equivalent, and are naturally gluten-free, made from tapioca flour.
• BBQ meat – Although barbequed meat is usually safe for celiacs, be aware that in Ecuador it is common to marinate the meat in beer before cooking.
• Top Dish: 'Open Original Shared Link' – The national dish of the country is a fish soup with boiled yucca and red onions.

Celiac.com 08/04/2016 - Did, or do you know the hidden dangers of celiac disease? Often we can spout off some of the things we have been told, heard or learned on this gluten free journey, but do you know the hidden dangers of unchecked or ignored celiac disease or gluten sensitivity? I myself was shocked by some of the research that is out there about the damage of consuming gluten. Some people who are diagnosed quickly are able to reverse the certain hidden and unknown problems.

Did You Know that Medical facts listed by the Canadian Celiac Association in their Medical Facts bulletin of 2016 indicate that celiac disease now affects between 0.5% - 1% of the population of the USA, which is similar to the prevalence reported in Europe? World prevalence is estimated at 1 in 166, and celiac disease is now recognized as one of the most common inherited diseases. Did you know that it is the "untreated", (non-compliance to the strict adherence to the gluten-free diet) that can cause so many symptoms other than the gastrointestinal symptoms and villus atrophy that occurs in the majority of cases?

Let's start out with the basic information that this is a genetically-based autoimmune disorder in which specific peptides from wheat, rye and barley (commonly referred to as "gluten") trigger progressive destruction of the villi of the small intestine. Gluten consumption can result in deficiencies of iron, folate, calcium and the fat-soluble vitamins (A,D,E & K) and an increased risk of osteoporosis, infertility and specific cancers of the gut.

Did you know that the celiac has an increased risk of osteoporosis, infertility and specific cancers of the gut? This information is not intended to scare you with threats of the "BIG C", we all have enough fear of cancer, but it is intended to wake us all up to the complications of untreated celiac disease. The National Institute of Health warns of the following complications of celiac disease in patients who DO NOT follow the gluten-free diet. These problems can usually be blamed for the "symptoms of celiac disease" that are present when the patient is first diagnosed. In many cases, these complications can improve or go away completely if a gluten-free diet is STRICTLY followed. Sadly, there are still celiac patients who ignore the fact that this is a lifetime problem which as yet does not have a cure, despite false advertising to that effect (I was recently approached by someone who eagerly sells certain vitamins that guarantee they can rid me of not only celiac disease, but dermatitis herpetiformis (DH)--this person was involved in a multi-level marketing program that is inundating our local community, specifically approaching women who want to make additional income by selling this pre-packaged set of vitamins that come from Australia that are "guaranteed" to heal my autoimmune disorder).

Did you know that malnutrition is fairly common even when patients are eating lots of healthy foods? They can become malnourished because the nutrients in the food are not being absorbed. These so-called vitamins that guarantee to heal celiac disease are not the answer, and a strict adherence to the gluten-free diet is the only answer.

Vitamins and nutrients are excreted in the stool. Malnutrition caused by untreated celiac can cause weight loss, anaemia, and vitamin deficiencies that may result in fatigue, stunted growth, neurological problems, and low bone density. Science truly is sounding the alarm with regards to brain function and celiac disease, and new studies about what happens when gluten particles get into the brain of someone with celiac disease or gluten sensitivity are mind boggling.

Did you know that decreased calcium levels and osteoporosis, specifically calcium and vitamin D (which are lost in the stool instead of being absorbed into the body) are leading to rickets in children, a type of kidney stone called an oxalate stone, as well as osteomalacia (softening of the bone), osteopenia and osteoporosis? Those of you who have been diagnosed as having gluten sensitivity are not left out because bone diseases can occur in people with milder forms who do not appear to have malabsorption. In such people bone density can actually improve once the gluten-free diet is started.

Did you know that many celiac patients on the gluten-free diet find that once their intestines have healed, lactase (which helps us digest the lactose in dairy products and is produced in the cells that line the surface of the villi in the small intestine) production

The cancer concern, according to most studies, is most prevalent in long-standing UNTREATED celiac disease. Gastrointestinal cancer, such as lymphoma, even with this increased risk, is still noted as relatively rare according to Nancy Lepid, celiac disease and gluten sensitivity Expert. Yet people with celiac disease may have a near two-fold increased risk of coronary artery disease compared with the general population, according to research to be presented at the American College of Cardiology's 63rd Annual Scientific Session. This study is the first to look at the association between celiac disease and coronary artery disease and adds to the evolving understanding of how systemic inflammation and autoimmune processes might influence cardiovascular disease development. Data also showed a slightly higher risk of stroke among people with celiac disease compared to controls. Time and time again it is repeated that celiac disease is a chronic inflammatory condition of the digestive system that can damage the small intestine, eventually interfering with the absorption of key nutrients. People with celiac disease are unable to tolerate gluten because gluten is thought to trigger an immune and inflammatory response in the gut.

Did you know that researchers found a significantly higher prevalence of coronary artery disease among patients with celiac disease compared to the control population (90.5 percent compared to 5.6 percent, respectively)? Data showed a similar trend among younger patients those under age 65, (WOW!) That is younger!?!) Compared to those without celiac disease (4.5 percent compared to 2.4 percent). This is an important study because it highlights a specific patient population who might be at higher risk for coronary artery disease, even in the absence of traditional cardiovascular risk factors, according to R.D. Gajulapelli, M.D. , clinical associate at the Cleveland Clinic and co-investigator of the study. "Our findings reinforce the idea that chronic inflammation, whether it's from an infection or a disease, can have an adverse role in coronary artery disease and heart health in general."

I was urged to have bowel scopes every five years when I was diagnosed with celiac disease and dermatitis herpetiformis, but I was never informed of the increased risk of coronary artery disease, or that people with celiac disease were slightly more likely to have high cholesterol. Dr. Gajulapelli himself said: "We were surprised by the strength of the association of the high prevalence of coronary artery disease, "Especially" in younger people. Patients and doctors should be aware of this association. If celiac disease affects an estimated 1 in 133 Americans, but experts believe upwards of 80 percent of people with celiac disease are under-diagnosed or misdiagnosed with conditions such as lactose intolerance and irritable bowel (often called the "Catch-all" diagnoses when a physician does not know what is wrong with a patient). Previous research shows celiac disease has been on the rise and is four times more common now than it was 50 years ago. The only treatment for celiac disease is adopting a gluten-free diet.

So you believe that these rapidly growing numbers are directly related to earlier or better diagnosis, or the education of physicians today? I prefer to believe that it is the better education of the family physician with regard to the signs of celiac disease.

To close I wanted to surprise you with some statistics with regards to the sales of gluten-free products, which in 2010 reached $2.6 billion, and were expected to exceed more than $5 billion in 2015. This year, with the increase in prepackaged gluten-free foods and the marketing restaurant guidelines one could estimate that it will be well over $15 billion. Celiac patients used to have to prepare everything from scratch, but we are quickly buying into the boxed fast-food "celiac generation".

Tip 1: Look for Healthy Food Items

There are numerous food items which are naturally gluten-free. Stop worrying about the "off-limits" items, as there are plenty of healthy and gluten-free alternatives. These include the energetic ones such as meat, vegetables, fruits, poultry, fish, eggs, cheese, dairy items, nuts, legumes and beans. Above all, you should always consider eating food items that are healthy, and will help you maintain your physical fitness and body tone, rather than unhealthy replacements for the items you miss.

Tip 2: Avoid Eating Items Containing Gluten

Wheat gluten is one of the staple food items and is enemy number one for people who are suffering from gluten sensitivity. You should avoid foods that contain any gluten. It is not just wheat that is harmful for those with celiac disease, harmful gluten is also present in barley, rye, bulgur, seitan, and many other foods in for form of additives and thickeners in things like chicken broth, salad dressings, malt vinegar, soy sauce, etc.

However, not all grains need to be avoided, and you can eat foods made from corn, buckwheat, teff, amaranth, millet and quinoa, which are naturally gluten-free. Of course you need to be sure that you get uncontaminated versions, as some grains can be contaminated during processing.

Tip 3: Make a Habit of Reading the Food Labels

Now that you know that you must avoid gluten, it is time to take care of your diet. When going grocery shopping you should make a habit of reading the ingredient labels, which all foods should have on their labels.

While reading it, you will get an idea whether or not the product is suitable for you or not. You should carefully look out for ingredients including rye, wheat, barley, or any ingredient containing gluten. If you find any of these ingredients, avoid purchasing them and opt for other alternatives.

Tip 4: Be Vigilant When You Eat Out

Having celiac disease and being on a gluten free diet, does not mean that you should avoid going to restaurants and eating out. You can eat out but you need to be careful with the food items that you choose to eat, and how you order your food. Try to stick with a gluten-free menu if they have one, or foods that you understand the basic preparation methods and ingredients, for example steamed vegetables and grilled meats. Above all be sure that you are sticking to your gluten-free diet to maintain your health and fitness. When there is no gluten-free menue it might make sense to avoid eating fried items and foods containing sauces, because they can be a source of hidden gluten. It is always wise to inform your chef beforehand about the dietary restrictions for a safe gluten-free eat-out.

People with celiac disease can sometimes feel miserable due to their restricted diet, but they should not be sad because gluten-free meals can also be delicious and healthy, and often taste just as good as the foods that contain gluten.

Now that you know these tips, we hope you will be able to get started with your gluten-free diet effectively.

Sources:

• Open Original Shared Link

Celiac.com 07/29/2016 - Celiac is an autoimmune condition, and along with other autoimmune diseases, scientists are beginning to have a larger context for understanding what could be contributing to its immune dysregulation. In the last decades we've seen diseases becoming prevalent now that look very different from the diseases of our ancestors. The American Autoimmune and Related Diseases Association lists 159 autoimmune diseases on their website (1), but most of these diseases are very new.

In recent years, scientists began to identify and explore a new complex that was identified within our cells and belongs to our immunological line of defense. This new player is part of innate immunity, which is also called cell-mediated immunity. This is our body's rapid responder, and its approach to immunity is more like hand to hand combat. Its role is surveillance, and it uses generalized markers to identify something as an enemy and something the immune system needs to defeat. It looks for evidence of infection from bacteria, fungi, viruses and parasites but it also analyzes cellular debris. It is looking for any sort of danger signal that conveys the message that life is not normal as it ought to be (2). This analysis can even include looking for changes in pH (3).

The innate branch of the immune system is dependent on cells that are called phagocytes, and these cells like to engulf small pieces of things they encounter, in a process called phagocytosis. Often these cells will be breaking down those pieces it engulfs and then will returning the nutrition it contained back into the extracellular space. After fragments from outside are internalized, cells needed a way to decide if what was engulfed should lead to a stepped up immune response. That's why it is not surprising that scientists recently discovered a whole network of molecules internal to these cells that form a complex called an inflammasome. There are various types of inflammasome that cover different biological niches (4).

What this means is that, in response to what is deemed an enemy, a phagocytic cell will gather together a distinctive list of parts to assemble into an inflammasome, and then that inflammasome will produce specific cytokines called IL-1 beta and IL-18. These chemical messengers can then go and recruit more help.

In contrast, antibody mediated immunity is more like having an air defense. The antibodies made by this part of our immune system function more like missiles that are sent out to find a designated target.
Vaccines are designed for the antibody side of the immune response. Future recognition of a previous invader involves selecting a piece of protein, called a peptide, that is large enough to recognize. This side of our immune response forms a memory of that peptide so that in the future, our cells will use that memory to recognize that we have seen that germ before. If the germ is recognized from a previous infection, then the immune system can respond very quickly and with more hands on deck. The piece of the intruder's identity that will be remembered is determined by our HLA type, and that is determined by a section of DNA on our sixth chromosome. The vulnerability to celiac disease is defined by the genes that are behind the formation of HLA-DQ2 and/or HLA-DQ8.

Scientists have known for many years that these two branches of immunity compete with each other and need to stay in balance. The chemical immune messengers called cytokines will shift our immune response between a dominance of cell mediated or antibody-mediated immunity. Until very recently, all the attention in celiac was on the antibody mediated branch whose major decision-makers are T cells, but even T cells can form inflammasomes (5).

Scientists are now studying the innate immune response to gluten. Our innate immunity relies on a specialized call type called a phagocyte. Cells of this type of include monocytes, macrophages, neutrophils, granuloctyes, mast cells, dendritic cells, osteoclasts and even migroglial cells in the brain. Phagocytic cells will incorporate debris that comes close to them into a vesicle, and that is a sort of bubble with liquid and other contents inside. This vesicle is taken into the cell through a process called endocytosis. After that, this type of cell will quickly process the contents of that vesicle probably much faster than other cell types. This competence is likely why this type of cell is given the job of surveillance for invaders. It is also is useful as a tool for recycling things from the outside that they take in. Scientists prefer to call this set of cells the professional phagocytic cells. Other cell types can be enlisted for the job of phagocytosis but they don't have that role as their main purpose. That is why this different set is called the non-professional phagocytic cells and they may also form inflammasomes but may need more stimulation. (6).

Scientists in the last decade have done experiments to learn how inflammasomes work. These intracellular immune complexes are assembled often in response to exposures to a type of molecule called a lipopolysaccharide that can be detected after engulfing the cell membranes of invading organisms. There are many other triggers, all recognized by their ability to tell us when something inside us is not as it should be. ATP, our body's energy molecule, when it is identified as coming in from the outside, can be a trigger for the inflammasome. Engulfing this sort of molecule suggests to our phagocytes that cell death events may have occurred in the environment of that cell (7). Some of our cells have been found to extrude nucleotides in self-defense, because leftovers from that kind of event may tell the inflammasome machinery that the cell is encountering a dangerous situation (8).

This system recognizes that certain pathogens create holes in cell walls, so when a phagocyte encounters evidence of damaged membranes with holes in them, that alone can trigger a cell danger response that enlists inflammasomes. That means two popularly used medicines that kill fungus by inserting holes in their cells, Nystatin and Amphotericin B, have by themselves been found to create this danger signal even when there is no infectious agent. Doctors and lay people need to know that many signs that are usually associated with an infection, including fever, can occur when there is nothing infectious involved (9). Another inflammasome trigger is excess alcohol which can be very damaging when it triggers inflammasomes in the nervous system. (10) Another concern is environmental contaminates like asbestos and silica which have been studied the most when they are inhaled. (11)

Crystals of uric acid associated with gout or other cell debris can also trigger the inflammasome, as can crystals of oxalate, which may be important to celiac disease since scientists have found higher levels of oxalate in celiac sprue. These crystals must reach a critical concentration to generate this cell danger mechanism in phagocytic cells (12). In the past, nobody really was aware that oxalate could have a major effect on the immune system outside of what it does in the kidneys.

Scientists for so many years thought the kidney alone contained cells that oxalate could influence. That's why other cell types were not studied. At least now, we realize this narrow focus had been based on some premature conclusions. We should have known to look more broadly because there was so much evidence from Primary Hyperoxaluria, a genetic disorder where a defective liver produces oxalate that travels to the whole body, creating a condition called oxalosis. That's how we know that oxalate goes all over the body. For the longest time, nobody was measuring oxalate outside of kidney disease, even though there were a few exceptions, like in people after bariatric surgery, and in celiac sprue and in cystic fibrosis, and eventually, in autism (13).

Because there already was a literature about oxalate in celiac sprue, when our project began, we started informing the public about these links on our website, www.lowoxalate.info. More recently we have written a series of articles about oxalate in this journal, discussing the science, and also practical issues about how to reduce oxalate while on a gluten free diet. That was working with knowledge we had then, but now we know that this issue of inflammasomes has been a part of the story we didn't know, but it holds great promise of possibly addressing why there could be complications in celiac sprue that do not resolve by merely going gluten free.
Another trigger for the inflammasome is homocysteine (14). The pathway to recycle homocysteine back to methionine is called remethylation, and this process requires both methylcobalamin and the folic acid cycle. Others on internet groups have brought attention to polymorphisms in one of the relevant enzymes, called MTHFR. This system is also tied to the process of making sulfate, taurine and glutathione, because homocysteine can be routed that direction when the body is trying to resolve oxidative stress. Many of these steps require B6, and heme is also needed to direct homocysteine towards transsulfuration. The issue of excess homocysteine may prove to be more important to our non-professional phagocytic cells that are found lining our blood vessels, because these same vessels can also take up oxalate, creating a condition of vascular swelling called livedo reticularis (15). Issues with both homocysteine and oxalate have been associated with atherosclerosis (16).

Did your child's pediatrician recommend giving your child Tylenol before his immunizations to make him more comfortable about his body's reaction to his shots? Scientists have now found that Tylenol not only depletes our body's ability to deal with the oxidative stress from immunization, but it also turns on the inflammasome (17). The inflammasome will skew immune defense away from Th2 adaptive immunity, and that is unfortunate, in this case, because the process of developing a Th2 response was the whole point of giving a child a vaccine. Our vaccines are designed to contain adjuvants that skew the immune response in the Th2 direction (18) but some adjuvants may not be working as expected (19).

Researchers sometimes look for the evidence that someone has developed antibodies before they will call an immunization a success. That test will ordinarily not be ordered by a pediatrician, but instead, a child will simply later be given, by default, a booster shot. Is there any chance the recommendation of Tylenol or other inflammasome activators could have impaired the antibody response in some children? Certainly, the new research on inflammasomes might suggest that in children who fail to make antibodies after a vaccine, a look at what is happening with innate immunity could be in order before assuming that these systems are working normally. Are doctors testing antibody titres or doing other immune testing in children with celiac sprue? This may be more important if such a child has developed another autoimmune condition.
Has gluten had other ways of affecting the immune response? We have known that gluten and proteins from milk, soy, and even spinach will form opioid peptides as they are broken down. Like other opiates, these active peptides can be addictive and would be able to skew an immune response (20).Opioids can also paradoxically activate inflammasomes in the spinal column which then may provoke, amplify, and prolong pain. (21) Other work showed us that activation at the same opioid receptors that drugs use can limit our absorption of the amino acid cysteine. This amino acid is needed by our bodies in order to provide glutathione, the primary cellular antioxidant that protects us from oxidative stress, and this is especially important to save us from neurodgeneration (22).

Why is that important? The formation of glutathione can calm down a mitochondrion that is upset enough for it to be generating reactive oxygen species (ROS). Unfortunately, scientists recently learned that the ROS produced by a mitochondrion under such stress will also trigger the inflammasome. Having adequate glutathione is especially important when our bodies are coping with the demands of immune activity, as during illness or after immunization. Unfortunately, oxalate at those times may compete with glutathione for entry into the mitochondrion at the mitochondrial dicarboxylate carrier (23).

Until very recently, we did not know that partially digested pieces formed from gliadin could trigger the formation of the inflammasome. This occurred more in peripheral blood mononuclear cells (PBMCs) from people with celiac sprue compared to healthy donors (24). The people who did this research may not have known that people with celiac tend to be higher in oxalate than other people, and they also may not have known that oxalate by itself has been found to trigger the formation of the inflammasome. People with celiac may need to be careful about avoiding both triggers for inflammasome formation.

In a different context, another group of scientists discovered that PBMC's exposed to titanium salts made from oxalate caused immunotoxicity when other salts of titanium did not produce that toxic effect. That experiment tells us that oxalate does enter the type of cell that was also found to respond in celiac disease to these digests of gliadin by formation of the inflammasome (25).

The well-studied vulnerability of individuals with celiac to antibody mediated effects of gliadin came from the adaptive arm of our immunity. The HLA type is definitely known to be relevant there, but it would not be relevant to an issue of cell-mediated immunity. That is why it is a puzzle that the authors of this study did not control for oxalate by matching the control and celiac subjects for the oxalate content of their cells.
The differences they saw in response to the gliadin digest may have required higher levels of oxalate in those cells. Do we know? If that could be the case, then it becomes possible that the response they recorded in celiac cells might also happen in those who are higher in oxalate for other reasons, but who lack the HLA risk genes that are definitional of celiac. We simply cannot tell if the risk of inflammasome activation in their experiment involved having the oxalate content of these cells also working in some kind of synergism with gluten. It is important to note that here we are talking about oxalate that this type of cell may have accumulated earlier in its life or during its time in the blood. Here we are not talking about oxalate that someone may have just eaten.

It is possible that an inflammasome-mediated function could explain why there are so many people who don't have celiac disease discovering that removing gluten from the diet makes them feel better. The academic community and others are still having a hard time believing this story (26), and cannot understand the recent popularity of gluten free foods in the general population.

A different reason for thinking about a possible synergism between a gluten free and a reduced oxalate diet came from a recent poll done by the Oxalate Project at Open Original Shared Link. Those results revealed that the majority of those who reported positive effects in their autoimmune disease by reducing oxalate had been extremely high in oxalate before they reduced oxalate. Curiously, 58% of those responding to the poll said they were also gluten free, but only 16% had celiac sprue. Those who were both gluten free and low oxalate reported a 10% higher positive effect from reducing oxalate than those who were not also gluten free. That could be important.

Many scientists still think a standard American diet will keep oxalate below 200 mgs a day, but 84% of the individuals answering that poll said that they started out with levels of oxalate over 300 mgs a day. Recent changes in eating habits for high oxalate foods may have been the result of powerful advertising that has been telling people that high oxalate foods are the healthiest foods available. Anonymous poll data has no way to be verified, and that fact keeps us from assuming that we can derive information from this poll about oxalate's role (if any) in contributing to their autoimmune condition. Even so, the poll told us that out of all respondents, 73% reported a positive effect in their autoimmune condition by reducing oxalate, but those with celiac sprue (some who had other autoimmune conditions) did much better. 88% of them reported a positive effect on their autoimmune condition. That was actually a higher percentage than what was recorded for any of the other autoimmune conditions. Does that mean that it might be important for autoinflammatory processes to be careful about both gluten and oxalate? (27) We may learn the answer to that question as more people with these issues try both dietary changes together.

Some scientists now are generating data that they feel supports the idea that excessive activity of inflammasomes could be related to the etiology of autoimmune disease (28). The changes that the inflammasome makes to our bodies can be harsh, and in fact, some scientists studied sepsis in animals and found that just by blocking inflammasome activity by various inhibitors, they could save those animals from a certain death. The irony is that the animals were still infected, but survived anyway. That means that what had been killing them was their immunological response to infection instead of the infection itself. This type of research is still very new, but it may change some of our assumptions (29).

What interventions have scientists found that will suppress inflammasome activity? The good news is that a lot of their research has involved supplements that anyone can buy in a health food store, and some people were already using them for different reasons. One of those items is resveratrol. When it was first studied, it seemed to have been made out of red wine, mostly, but our project has discovered that commercially, the usual product is made from an herb called Japanese knotwood, which is known to be high in oxalate (30). The Oxalate Project has not yet tested the oxalate content of commercially available brands of resveratrol to see how much oxalate ends up in a capsule, but that testing is on its agenda.

The supplement quercitin is also an inflammasome inhibitor (31). CoQ10 is another supplement that has become widely available in drug stores and health food stores because it is needed to correct a mitochondrial problem created by statin drugs. Fortunately, CoQ10 also inhibits the inflammasome, mainly by keeping the mitochondrion happier and better protected from the need to generate reactive oxygen species (32). A popular source of sulfur called MSM (methylsulfonylmethane) also was found to inhibit inflammasomes (33). So has its close cousin DMSO, a solvent that was once used as a delivery system for secretin, when it was proposed as a treatment for autism (34, 35).

Another exciting inhibitor is 3-hydroxybutyrate, which is one of the two ketones (along with acetoacetate) that our bodies make in ketosis (36). Ketosis occurs when the body is not getting enough energy from carbohydrate, and it switches into a mode of burning fat, and that produces these ketones. Some people will try to induce this switch in metabolism on purpose, like those dealing with seizures who find the seizures are controlled with a ketogenic diet. If the change that this ketogenic diet accomplished was due to down regulation of inflammasome activity, that might bring new hope or strategies to mind for individuals where this diet treatment by itself failed. Such individuals may have had a different environmental component that was still activating inflammasomes in spite of their use of the use of the ketogenic diet. This mechanism may point to yet another reason that obesity, which may have come from excess consumption of carbohydrate, has been linked with inflammasome activation (37).

We can hope that more investigation of other activators and other inhibitors for those with seizures might yield better success. Also, the association with ketosis may explain a previously overlooked benefit experienced by people who were exercising the discipline of fasting…the age-old tradition that comes from many cultures. These traditions are more striking when realizing that obesity can activate inflammasomes and inflammasomes are thought to be behind the roots of metabolic syndrome and diabetes (38, 39).

Pharma does have some drugs already in its cabinet which scientists have found will inhibit inflammasomes. There are probably more such drugs in the pipeline and we may soon hear advertisements for this new class of drugs. Our Oxalate project has already begun to hear of some doctors and hospitals using the over the counter inhibitors resveratrol or coQ10 to successfully protect patients who were at risk for developing sepsis.
More research obviously needs to be done in this area and this new frontier has become very attractive to scientists. One of the first big questions they may need to ask is whether our health care protocols in Western medicine have led to over-stimulating this arm of immunity by emphasizing killing strategies with antimicrobial therapies or other drugs that may leave crystals or other debris behind. Why might that have been a problem?

Phagocytes are upset about cellular debris and disrupted membranes. Some scientists have been finding that our bodies may stay healthier by tolerating some infections rather than experiencing the excessive immune activity that comes from activating inflammasomes. It will take a long time for some of these scientific ideas to trickle down and begin persuading doctors to make changes in their prescribing habits for antibiotics and other antimicrobials. Some doctors and other practitioners are already finding that inflammasome inhibitors could be an appropriate adjunct therapy during antibiotics. Of course, since this is such a new scientific area to study, it may take years before proper clinical studies can be done to address all these issues.

In the meantime, it seems wise for anyone prone to autoimmune disease to avoid triggers for inflammasomes that are easy to avoid. This would include things like being overweight, eating foods that encourage uric acid formation (and the risks known for gout). It could include situations that encourage the body to make oxalate and that could include deficiencies of B6 or thiamine, or excess use of Vitamin C. It could come from excess dietary oxalate. We also need to consider the use of drugs or supplements that are known to form crystals in blood, or Tylenol, or antifungals that punch holes in cell membranes. We need to be vigilant about our status for homocysteine. We need to be careful about our level of consumption of alcoholand our exposureto other environmental contaminants. In time, we will learn of many other triggers.

If there is a suspicion that inflammasomes are related to a disease process that we find in our bodies, then we should at least think about using one of the over the counter and safe and well-studied inflammasome suppressors. As the research continues, we can hope that scientists studying in this area will show us more ways to dial down the frequency and the unpleasant symptoms and other consequences of autoimmune disease and autoinflammation.

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This spring, I started becoming so tired that I couldn't wait to go to bed, even though the sun was still shining. I finally went in to see my MD who took my blood for testing. The results? I had no vitamin D. None. I have a good diet (see my book Going Gluten Free for proof of this!), and I know that vitamins are important. I know that sunshine is associated with vitamin D, and while I'm not outside all the time, I'm not like a vampire that only goes out at night. I do get sunshine. I also have a sun lamp over my desk. So why did my blood levels indicate I have no vitamin D? Evidently I'm in good company again – lots of people with celiac disease have vitamin D problems.

Vitamin D is unique. Evidently Vitamin D isn't really a vitamin at all – it is a secosteroid, a hormonal precursor that is similar to other steroids that the body makes, such as cholesterol, testosterone or cortisol. Vitamin D obtained from sun exposure, food, and supplements is biologically inert and must undergo two hydroxylations in the body for activation. The first occurs in the liver and converts vitamin D to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol. The second occurs primarily in the kidney and forms the physiologically active 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol. Vitamin D promotes calcium absorption and is necessary for variety of health processes, including the creation of strong bones, modulation of cell growth, neuromuscular and immune functions, and the reduction of inflammation. Vitamin D is located in the nuclei through a receptor. It impacts the creation of proteins that then transport calcium or phosphorous, which bones and other body functions require for healthy development. Vitamin D stimulates how the intestine absorbs calcium and mobilizes phosphate levels. Without vitamin D, our bodies and our lives are in trouble.

I'm not a nutritionist – I'm a film maker. But from what I have learned, low vitamin D levels in one's body is associated with how well the body can absorb calcium. I had no idea that I was deficient in vitamin. Some people may not experience any symptoms of it at all. Symptoms of vitamin D deficiency are sometimes vague. They can include tiredness and general weakness, aches and pains, which may result in people feeling like they can't move around as well as they wish. Some folks experience frequent infections. There is no way to know if you have a vitamin D deficiency or not unless you get a blood test. Doctors measure if you're deficient in vitamin D by testing your 25(OH)D level. Getting a blood test is the only accurate way to know if you're deficient or not.

Vitamin D deficiency is thought to be related to having a "leaky gut." Research indicates that vitamin D can be helpful to maintaining tight junctions in the small intestine that regulate what gets in and what stays out. Dr. Tom O'Bryan describes this to be similar to a rubber band wrapped around the junctions; if it gets too stretched out it may lose its elasticity and ability to snap back in place. People who are deficient in vitamin D tend to have rubber bands that aren't operating normally and allow foreign material to leak into the body, which can promote inflammation. Vitamin D seems to modulate the immune system and regulate the inflammation to keep it in check. In particular, it has been found to inhibit the development of a variety of other autoimmune diseases.

If you've got a vitamin D deficiency, you better do something about it, otherwise you exacerbate the possibility of future health problems. Dr. Lisa Watson has found that low vitamin D levels decrease the amount of calcium that a body can absorb, and for those of us with very low vitamin D it is possible that only 10-15% of dietary calcium is absorbed (compared to 30-40% in healthy individuals). Other experts report that because people with Celiac disease have villous atrophy, we have malabsorption issues that may ultimately modify that way our immune systems react, which can lead to further autoimmune diseases. Lower absorption of calcium is also related to bone diseases, brittle bones, and osteoporosis - which makes me reconsider about why my ankle was so weak that I ended up having surgery on it a few years ago.

So what are people like us to do? First thing is to see a doctor and have a blood test so you can get an accurate indication of if you actually have a vitamin D deficiency, and if you do how much of a deficiency you have. Don't try to self-diagnose your condition. It's tempting to do this. But go see your doc or an expert in the field. It seems that serum concentration of 25(OH)D is the best indicator of vitamin D status, so that's probably what test they will run.

Don't go to the store and buy vitamin D and start taking it without knowing what you are doing. How much a person needs varies by the individual. There are vitamin D supplements available, but it is not wise to start self-medicating and guessing at how much you should take. Get a professional opinion and follow it. Get your serum blood levels tested regularly, monitoring it to make certain you're on the right amount. Evidently the amount of stress one is under, the time of the year, what one is eating and other factors may influence absorption levels. There is such a thing as vitamin D toxicity where people can take too much of a good thing. So find out from the doctor exactly what amounts you should be taking.

It's important to figure out exactly why you have the vitamin D deficiency. Perhaps it is associated with your diet or lifestyle. It is possible to alter our diets and eat more foods that are in our best interests. Actually, very few foods naturally contain high amounts of vitamin D. The flesh of fatty fish like salmon, tuna, and mackerel and cod liver oils are among the best sources of vitamin D. Smaller amounts of vitamin D can be found in beef liver, cheese, mushrooms and egg yolks. Foods, like milk and milk products that are fortified with vitamin D, provide most of the vitamin D for people in the USA. If you take vitamin D supplements, addressing them could do the trick for you.

Most of us could get out into the sun more, but if we've got a malabsorption issue the amount of vitamin D we get from the sun may actually not matter that much. It never hurts to get into the sun (with moderation, of course). Doctors may tell you to get out into the sunshine, since ultraviolet rays from the sun interface with the body to activate it through vitamin D receptors. These receptors are located throughout the body, including the brain, heart, skin, and a variety of other organs. But it's not as simple as just getting out and talking a walk. Season, time of day, length of day, cloud cover, smog, skin melanin content, and sunscreen are among the factors that affect UV radiation exposure and vitamin D synthesis. Sales of ultraviolet ray lamps have increased dramatically with people who have to stay inside doing work under them just so they can capture some Vitamin D. But for some of us with celiac disease, we can't get enough of it by being out in the sun, sitting under the lamp or eating the right diet. We have vitamin D problems mostly because our bodies can't absorb it properly.

It's important to pay attention to what your body is telling you. When something doesn't seem quite right, it's important to then do something about it – like going to a professional who can diagnose, treat and prescribe. It could be that you, like me, keep realizing new ways that Celiac impairs our lives. Celiac is not for sissies. If you've got it, you've got to work with your body, listen to it, and take actions to honor it. By working with health professionals who know about celiac disease, keeping up with the research, being diligent and having a positive attitude, we can still live good and healthy lives.

Based on its review of data of vitamin D needs, a committee of the Institute of Medicine concluded that persons are at risk of vitamin D deficiency at serum 25(OH)D concentrations 125 nmol/L (>50 ng/mL) are associated with potential adverse effects [1] (Table 1).

* Serum concentrations of 25(OH)D are reported in both nanomoles
per liter (nmol/L) and nanograms per milliliter (ng/mL).
** 1 nmol/L = 0.4 ng/mL

Reference Intakes
Intake reference values for vitamin D and other nutrients are provided in the Dietary Reference Intakes (DRIs) developed by the Food and Nutrition Board (FNB) at the Institute of Medicine of The National Academies (formerly National Academy of Sciences) [1]. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and gender, include:
30. Recommended Dietary Allowance (RDA): average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%–98%) healthy people.
31. Adequate Intake (AI): established when evidence is insufficient to develop an RDA and is set at a level assumed to ensure nutritional adequacy.
32. Tolerable Upper Intake Level (UL): maximum daily intake unlikely to cause adverse health effects.
The FNB established an RDA for vitamin D representing a daily intake that is sufficient to maintain bone health and normal calcium metabolism in healthy people. RDAs for vitamin D are listed in both International Units (IUs) and micrograms (mcg); the biological activity of 40 IU is equal to 1 mcg (Table 2). Even though sunlight may be a major source of vitamin D for some, the vitamin D RDAs are set on the basis of minimal sun exposure.

References:

• Gluten Free Society. Celiac disease linked to gall bladder and liver problems. Open Original Shared Link
• Holick MF. Vitamin D and Health: Evolution, Biologic Functions, and Recommended Dietary Intakes of Vitamin D. In Vitamin 😧 Physiology, Molecular Biology and Clinical Applications by Holick MF. Humana Press 2010.
• Middleton, Bert. Gout and Celiac Disease: What is the connection? Open Original Shared Link
• National Institutes of Health. Office of Dietary Supplements. Vitamin D. Open Original Shared Link
• Reasoner, Jordan. Why everyone with celiac disease desperately needs vitamin D. Open Original Shared Link
• Rottman, Leon. Vitamin D revisited. Open Original Shared Link
• Tavakkoli, A. Open Original Shared Link. 
• Tavakkoli A, Digiacomo D, Green PH, Lebwohl B. Vitamin D Status and Concomitant Autoimmunity in Celiac Disease. J Clin Gastroenterol. 2013; Jan 16.
• Vitamin D Council. Am I deficient in Vitamin D? Open Original Shared Link
• Watson, Lisa. Nutrient Deficiencies in Celiac Disease. Open Original Shared Link

Celiac.com 07/22/2016 - Some of us have the luxury of living in a household that is completely dedicated to being gluten-free. However, many of us don't have that luxury. So, there are certain precautions you must take, in order to avoid cross contamination.

Now, here is a list of helpful tips to keep in mind for your kitchen:

1. Always wear gloves or wash your hands thoroughly, especially if you have dermatitis herpetiformis (DH), when you are wiping down counter tops, tables and stove tops. Using paper towels would be a beneficial because you can throw it directly in the trash. As for hand towels, have a separate one for your hands.
2. Having a dishwasher or even a counter top dishwasher, if possible, reduces your worries. Otherwise, be sure to have different sponges when washing because they are very porous and absorbs gluten.
3. For your kitchenware, having glass, metal, stainless steel and ceramic would be best because plastic and wood absorb gluten as well. Just think about your flour sifters, colanders and cutting boards.
4. As for appliances, have separate toasters, baking mixers, convection ovens, blenders, etc.
5. Keep cabinets and refrigerator shelves separate, especially from foods like cakes, cookies, breads and crackers. Basically, anything that can cause a lot of crumbs. Also keep your flours and wheat flours in labeled, air tight containers, so they are completely sealed shut. You do not want flour flying everywhere.
6. When reheating your food, cover all your plates in the microwave.

Lastly, if you are following all of these instructions correctly and consistently, your celiac disease should stay under control. However, it might be best if you get your antibody levels tested at least once or twice a year by your gastrointestinal (GI) physician. That way you can see, in black and white, that all your antibodies are in range. That will prove you're keeping yourself perfectly healthy.

References:

• Open Original Shared Link
• Open Original Shared Link

While phosphorus is considered an essential nutrient, the increased amounts found in processed foods via additives like anti-caking agents, stabilizers and leavening agents or acidifiers does not have to be stated on the nutrition label. Individuals following a gluten-free diet need to consider the health implications of phosphates found in processed foods eaten regularly in their diet. Reducing carbonated beverages is the best way to reduce phosphorus levels in the diet. Extra attention needs to be paid to the ingredient statement on foods.

Ingredient statements may include these declarations: tri-calcium phosphate, tri-magnesium phosphate, disodium phosphate, di-potassium phosphate. Just because the label states "natural" or "organic" does not mean it is a healthy food for daily consumption. Fresh is best!

Here is a guide to where phosphates can be found in gluten-free processed foods:

• Baked goods- cake mixes, donuts, refrigerated dough (pyrophosphates are used for leavening and as a dough "improver")
• Beverages- phosphoric acid in colas (acidulant), pyrophosphate in chocolate milk to suspend cocoa, pyrophosphate in buttermilk for protein dispersion, tri-calcium phosphate in orange juice for fortification, tetra-sodium phosphate in strawberry flavored milk to bind iron to pink color
• Cereals- phosphate in dry cereals to aid flow through extruder, fortification of vitamins
• Cheese- phosphoric acid in cottage cheese to set acidification, phosphate in dips, sauces, cheese slices and baked chips for emulsifying action and surface agent
• Imitation Dairy Products (non-dairy products)- phosphate as buffer for smooth mixing into coffee and as anti-caking agent for dry powders
• Egg Products- phosphate for stability and color + foam improvement
• Ice Cream- pyrophosphate to prevent gritty texture
• Meat Products- tri-phosphate for injections into ham, corned beef, sausage, franks, bologna, roast beef for moisture
• Nutrition Bars & Meal Replacement Drinks- phosphates for fortification and microbiological stability
• Potatoes- phosphate in baked potato chips to create bubbles on the surface, pyrophosphate in French fries, hash browns, potato flakes to inhibit iron induced blackening
• Poultry- tri-phosphate for moisture and removal of salmonella and campylobacter pathogens
• Pudding & Cheesecakes- phosphate to develop thickened texture
• Seafood- tri-phosphate in shrimp for mechanical peeling, pyrophosphate in canned tuna and crab to stabilize color and crystals, surimi (crab/sea sticks) tri-phosphate and pyrophosphate as cryoprotectant to protein {surimi contains gluten and is not recommended for gluten-free diets]

Hyperphosphate levels can contribute to muscle aches, calcification of coronary arteries and skeletal issues. Many food companies do not provide phosphorus analysis information because it is not required on the label but here is a representative sample of phosphorus levels in some commonly consumed on a gluten-free diet.

Peanuts (1 ounce) 150 mg
Yogurt (1 cup) 300 mg
M&M Peanuts (1.74 oz pkg) 93 mg
Rice Krispies Cereal (1 cup) 200 mg

Dietary recommendations for an adult for Phosphorus is 800 to 1000 mg.

As if to counter such negative press, I got this email last week:

By way of explanation, George was aggressive and having difficulty learning, he was easily distractible and he was always fighting with his sister. His parents saw him as being a naughty boy, however he was displaying severe ADHD behaviours. They wondered if he might need some medication and were exploring psychological help for their family.

However, as I have seen a lot of behaviour-disturbed children get completely better off gluten. So I tested him for celiac disease (this was negative), I then recommended a strict gluten-free trial for three months. As you have read, his parents say that there has been a dramatic change, and now see him as a "sociable and loveable little boy" – in just a few weeks!

To me this is clear evidence that gluten can cause significant inflammatory damage to our nerves and brains. George was displaying ADHD behaviours, triggered by gluten. It is a pity that those who are ridiculing the gluten-free diet movement are attempting to deny children like George the knowledge of healing on a gluten free diet.

Evidence points to the nervous system as the prime site of gluten damage. This theory is attractive because it gives a unifying answer that explains the following conundrums:

• a mechanism of the non-gut symptoms of celiac disease;
• the behaviour disturbances caused by gluten reactions;
• the psychiatric and personality disorders provoked by gluten;
• the multitude of neurological symptoms;
• the autonomic nervous system disturbances (often seen in people with celiac disease);
• why such small amounts of gluten can cause such major reactions by the amplification effect of the nervous system (not dependent on any gut damage);
• why gluten can create such a diverse range of symptoms. Because any agent that causes widespread neurological harm (think of multiple sclerosis and Syphilis) can generate almost any array of symptoms.

Nerve and brain damage from gluten can also explain why celiac patients with extensive gut damage can be asymptomatic. The histological gut damage in celiac disease is not mediated through this neurologic system: it is caused by local toxicity to the bowel in susceptible people. If these people are not highly sensitized to gluten, then they may not experience any symptoms mediated through neural networks.

I got mad and grumpy
I would also like to tell you about Nick. When he was 8 years old he wrote his story down for me:

I had dizzy spells
I also had dizzy spells every day and I didn't feel well. They thought that I had a heart problem when I was 8. I went to the doctor and to the hospital lots and lots as they were trying to figure out what was wrong with me. I wasn't very well. When I was on gluten I had sore tummies at least twice a week.

I am off gluten and I have more energy
Now I am on a gluten-free diet. When I'm off gluten, I still sometimes have dizzy spells – but not usually. You might lose weight when you first start go gluten-free because you are getting used to it.

At school I found I had to get off gluten, as I couldn't sit still on the mat. I now have got more energy to run. I can sprint now. I can sleep better too. I used to not have enough energy but now I have enough energy to sprint around the cross-country. I've achieved in my spelling now and I'm much better at school. My Doctor Ford is a nice man because he talks nicely. Tons of people need to go and see him.

Gluten-free helps your attitude
Please come to our diet because it helps you breath better, it helps your attitude change. It makes you be stronger. Me and my brother used to fight a lot when I was on gluten but we like one another now. I liked gluten foods but I can't have it as it's not good for me.
In my family we have got a dog and four humans – Jordan, Dad, Mum and me. We are all gluten-free but my dad doesn't have to be gluten-free. It's unfair when my dad eats gluten and it makes me feel hungry.

The food can be nice
Our gingerbread bakery bakes us nice food. When I found out I was allowed to have a gluten-free birthday cake I was very happy. We go to Gingerbreads once a week. I buy chocolate chip biscuits they taste delicious. World come and be gluten-free as it makes me delighted! I love people that make yummy gluten-free foods.

My brother says that being on a gluten-free diet is like being in China with no noodles. He finds it hard and says he just wants to be normal. I say he will get used to it.
Nick

Nick's mum adds:
Prior to going gluten-free Nick had the following list of symptoms:

• Rashes
• Sore tummy and runny poos
• Very irritable
• Very tired – slept more than 12 hours
• Poor memory and learning hard work
• Behaviour problems – got very angry with others
• Bad hay fever and asthma
• Intolerant to dairy
• Dizzy spells for 6 months and not feeling well
• Very fussy eater.

The good news is that of today (six months later), he is not having a lot of these symptoms and he is a much nicer person all around. He can now have dairy products again."

Mum
The implication of gluten causing neurologic network damage is immense. With estimates that at least one in 10 people are affected by gluten, the health impact in enormous. Understanding the components of the gluten syndrome is important for the health of the global community.

Written in the spirit of cooperation and knowledge sharing. You can read many more patient stories in my book "Gluten-Related Disorder: Sick? Tired? Grumpy?" Open Original Shared Link 

When you've got celiac disease and people aren't attentive to making sure you can eat gluten-free foods that are safely prepared and not contaminated, you can end up very sick in the short-run. The short-term effects may include symptoms such as gastrointestinal upset, migraines, fuzzy brain, sweats, and general malaise. As a fundamental right, what one eats should ensure people's access to a healthy, dignified and full life. People who have been "glutened" do not feel dignified as they writhe in pain, wrestle with fears of embarrassment, or modify their lifestyle and social schedules to accommodate the illness. In the long-run, if someone is continually exposed to gluten in foods, a variety of serious preventable health conditions may result. Unlike a peanut allergy that can directly kill you, exposure to gluten may result in morbidity and early mortality for people in an indirect fashion. Adhering to a gluten-free diet is of paramount importance to avoid health problems such as compromising one's weight and pubertal development, fertility, bone mineral density, and deficiencies of micro and macronutrients, not to mention the increased risk of developing malignancies, especially in the gastrointestinal system. Because the health effects of ingesting gluten for someone with celiac disease are less visible to those who don't experience them, they have been easier to ignore. Thanks to vocal advocates who now know that going gluten-free can save their lives, it is obvious that the lack of attention to making sure people can eat safely is a violation of their rights.

Let's put the issue of gluten into a larger rights context. The United Nations Declaration of Human Rights (UDHR) was adopted in 1948 after World War II and it is the first global document that codified rights to which all human beings are inherently entitled. It contains a wide range of rights and is regarded as the foundation upon which other rights documents have been built. Its Article 25 states that "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control" (Open Original Shared Link). The right to health and well-being are directly linked to food. Conditions like celiac disease, which are genetic in nature, are thus beyond one's control and necessary to be addressed through appropriate care and management.

In another rights treaty document that pertains directly to the rights of children and youth, the UN Convention on the Rights of the Child (UNCRC) addresses in Article 3 that "In all actions concerning children….the best interests of the child shall be a primary consideration", that individuals responsible for them are required to ensure that they receive the services and protections they need, particularly in the areas of safety (and) health…". Article 24 "recognizes the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services". It goes on to emphasize the importance of disease prevention and primary health care "through the provision of adequate nutritious foods" (Open Original Shared Link). This implies that nutritious foods are linked with disease prevention and well-being, and making sure children (and adults) get the proper foods is in their best interests. If a child has celiac disease and the responsible adults are inattentive to making sure they can eat safely, they are in fact violating the child's rights. There are, then, international treaties that link food and nutrition directly with human rights.

Juliana Nadal at the Department of Nutrition, Food Quality and Nutrition at the Federal University of Parana in Brazil reviews in her journal article, "The principle of human right to adequate food and celiac disease" (Demetra; 2013; 8(3); 411-423), a variety of ways that people who have celiac disease have their rights violated. Because celiac disease can be considered the most common food intolerance in the world, it is one that both individuals and social structures need to address as a mainstream issue. From how laws and consumer protections are designed at the macro level, to how food is made available and prepared at the micro level, rights of people with celiac disease hang in limbo. Some places and people are very attentive to their rights protections while others are not. Nadal contextualizes food and nutrition insecurity that afflicts individuals with celiac disease with specific regard to the principle of the Human Right to Adequate Food (HRAF).

Diet is the single most secure treatment form for people with celiac disease. Managing one's diet enables one to control the magnitude of the disease. Laws, standards, practices and policies are necessary to secure HRAF for people with celiac disease. It is therefore important that the public be educated regarding this. By protecting individual fundamental human right to food availability in both quantity and quality, it reflects the value of society to protect the welfare of this group of people. Ultimately, rights protections promote and improve the health of the entire population.

Rights violations may also be seen through the limited availability of products intended for celiac individuals in the market. Whether looking at gluten-free food as a local, state, regional, national or global issue, there are certain countries and areas that do not have access to the same quantity and variety of gluten-free foods as in other areas. Online shopping may make it easier for some people to access foods they need, but this option is not necessarily available to everyone. If foods essential for good diets are not accessible, this forces people to make dietary compromises that may not be in their best interest.

Another area of rights violations for people who have to go gluten-free is the high cost of products. Simply put, gluten-free foods tend to cost more than other foods. People who have celiac disease have to use more of their scarce dollars to pay for food. This means there is less money available to pay for other necessities. Because gluten-free foods tend to be more expensive, this creates a social class barrier, especially for poor people or financially-strapped people with celiac disease. Poorer people will have their right to safe nutrition compromised because they can't afford the same foods as more affluent people who have celiac disease.

The issue of gluten contamination contributes to a constant situation of food and nutritional insecurity to holders of this special dietary need. The celiac diet must be completely gluten-free, which allows people to have a life relatively free of major pathological complications. Maintaining a totally gluten-free diet is not an easy task because the violation of the diet may occur voluntarily or involuntarily, and range from incorrect information on food labels to the gluten contamination of processed products. Difficulties in the availability and access to food without gluten violates the principle of the human right to adequate food. The condition of being a celiac individual exposes one to permanent food and nutrition insecurity, which could cause loss of quality of life, socialization, and health of the individual, both in the short and long term.

The problematic situation of food and nutritional insecurity that afflicts individuals with celiac disease can productively be addressed with regard to the principle of the human right to adequate food (HRAF) from the perspective of Food and Nutrition Security (FNS). It is important to know and recognize the real need of the people who live in some way under threat of food insecurity, how it impacts their health and lifestyle. Constructing, implementing and improving health policies in order to meet their needs is imperative to provide access to adequate food of nutritional quality. and to ensure that food, biological, social and cultural needs are achieved.

By understanding food as a basic human right, it is easy to understand that the absence of safe foods that address the needs of celiac individuals represents a concrete case of a group of people who often may have their rights to adequate nutrition violated. As a result, many live in a state of food and nutrition insecurity. Food must be viewed as a constitutional right of all citizens, including those with special needs which require a special diet.

Celiac.com 07/07/2016 - Norelle R. Reilly, M.D., has offered several of her opinions regarding gluten-free diets in a commentary published in The Journal of Pediatrics, earlier this year (1). It is important to recognize the difference between this publication and a report of findings arising from a study. She didn't conduct a study. No ethical approval was cited or needed. Despite the inclusion of several tables and one graph, Dr. Reilly was only charting changes in the popular use of search terms between 2004 and 2015, on a single search engine, at Open Original Shared Link. Her tables simply provide explanations of several acronyms and a structure for her opinions, which may suggest more substance than her beliefs warrant. She simply formed a set of opinions that may or may not be supported by the research and other reports she cited. After all, Dr. Reilly had to interpret those studies so we aren't hearing from the investigators who actually conducted that research. We are just learning her interpretations of that research. Her clinical experience may or may not have factored into the opinions she offers, but since she failed to cite any such experience it seems most unlikely. She has also lumped all gluten-free diets into a single entity, which she labels GFD and which also poses several problems as you will see shortly.

Dr. Reilly has warned about the multiple hazards of the gluten free diet, especially for children. These hazards include its potential to cause harm due to its higher fat content, deficiencies in B vitamins and iron, as well as the increased costs of gluten-free food. She also points to social isolation and inconvenience as hazards of the gluten free diet, which would appear to include what she calls "a deterioration of their quality of life while on a GFD". She goes from there to say that the claim that "gluten is toxic" is a fiction for which there is no supporting evidence (1). She also says that those following a gluten free diet may be at greater risk from inorganic arsenic and/or mercury poisoning (1). She admonishes those who are at risk of developing celiac disease not to undertake a gluten-free diet "without first testing for celiac disease" and Dr. Reilly advises her readers that "there is no role for a GFD for children outside of treatment of celiac disease and wheat allergy" based on what she calls the "hazards" of this diet. She won't soon be going on my Christmas card list.

As many Journal of Gluten Sensitivity readers have heard before (from me), our pre-human line of primates split from our common primate ancestor with the bonobo chimpanzee sometime between 5 and 14 million years ago, depending on what source you read. Unlike our omnivorous, primate cousins, we humans have thrived in a wide range of habitats and have populated almost every part of our planet.

Some of us may have genes from ancestors who were cultivating and eating significant quantities of gluten grains as long as 10,000 to 15,000 years ago, in the Fertile Crescent of the Levant. Perhaps some human genes have been exposed to these grains for an even longer period. We really don't know. We can only judge based on the evidence we have. However, the evidence we have shows that most of the world's populations have had considerably less time to adapt to consuming these foods. Indigenous peoples of the Americas, Australia, as well as island dwellers from much of the Pacific Ocean, and even isolated groups of people in Europe and Asia have only consumed these foods for somewhere between 500 and about 5,000 years. A few of these populations, such as some groups of Canadian Inuit, some Pacific Islanders, etc. have only consumed gluten grains for less than 100 years. Yet Dr. Reilly would have us believe that the foods on which our forefathers thrived, while populating almost every habitable niche on earth, are somehow harmful. That seems a distinctly questionable perspective. She says that "The health and social consequences worthy of consideration in advance of starting a child on a GFD are not described adequately online or in books promoting an empiric GFD trial." Perhaps. That may simply result from the common awareness of the relatively short duration during which so many humans have consumed gluten-containing foods.

Further, Dr. Reilly's assertion that "This Commentary [sic] will provide an update on the current GFD fad ....." (1) suggests more than a small bias on her part. Has she undertaken to guide us through the facts, fiction, and fad of the GFD, while suffering the delusions of yet another fad herself? Is it possible that Dr. Reilly, in addition to eschewing some principles of natural selection and adaptation, is tending toward a paradigm that only counts gluten-induced disease when that ailment falls within her purview? This may be a trap set by today's trend toward the increasingly specialized study and practice of Medicine. Or it may reflect a less thoughtful resistance among these professionals, reminiscent of the 80 years' resistance to the germ theory.

Many neurologists, for instance, have been exploring a range of neurological ailments that are either triggered by gluten or are characterized by antigliadin antibodies found in the brain fluids of individuals afflicted by these neurological ailments (2). Some of these patients do have celiac disease but a majority do not(3). Yet their neurological ailments will often respond to a gluten free diet that must be more strict than is usually required to control celiac disease (4). In their work, Dr. Hadjivassiliou and colleagues have stated that "the neurological manifestations of celiac disease and NCGS are similar and equally responsive to a GFD suggestive of common pathophysiological mechanisms" (5). Thus, although Dr. Reilly is correct when she says that non-celiac gluten sensitivity (NCGS) is not yet well understood, it is quite clear that there is more information on the connection between gluten consumption and at least some cases of a wide range of neurological diseases (6, 7) than Dr. Reilly would like to credit. And these findings don't seem to be having much impact on many gastrointestinal researchers or practitioners. What is going on there?

Further, regardless of the state of the intestinal mucosa, dermatitis herpetiformis (which Dr. Reilly did mention) is yet another form of NCGS in which it is clear that gluten exposure triggers the onset of this malady and a gluten free diet controls it. Yet she fails to mention that a subset of schizophrenia patients also experience symptom remission on a gluten-free diet, even among pre-pubescent children (8) and the association between schizophrenia and gluten has been repeatedly reported in the literature over the last half century (9 -19). The immune reaction to gluten is usually not the same as that seen in celiac disease (17). Nonetheless, for this group, the underlying trigger is gluten and its dietary restriction can produce startlingly positive results (18, 19). These psychiatric ailments can have a devastating impact on the victims' lives and their families when a simple diet can sometimes provide an effective treatment.

While there is still some debate about whether gluten is the trigger in some cases of intestinal NCGS ailments, considerable evidence has also accrued showing that gluten is the trigger in a wide range of conditions both in association with untreated celiac disease and in the absence of celiac disease . The added problem is that Dr. Reilly has lumped all gluten free diets into a single entity. Yet many of us who avoid eating gluten also avoid other Neolithic foods, believing them to drive much of the current increases in autoimmunity, cancer, obesity, diabetes, and a host of other modern diseases. Dr. Loren Cordain's books have given rise to a large number of adherents to the "Paleo-Diet" that Cordain advocates (20). Other gluten avoiders find themselves developing symptoms when consuming "replacement" grains such as rice, corn, or millet, and choose to avoid those grains as well. Still other gluten avoiders subscribe to vegetarian diets, while others eat only organically produced meats and/or vegetables. These dietary practices also vary according to geographic location, all while avoiding gluten consumption. For instance, these variations might include increased fish consumption near the seashore and increased beef consumption inland, increased yak milk consumption in the Himalayas and increased millet consumption in West Africa. Thus, it seems questionable to lump all gluten avoiders into a single group, then suggest that they are suffering social isolation, lower quality of life, arsenic and/or mercury poisoning, and a host of other hazards.

Dr. Reilly has argued that "The gluten-free diet (GFD) is a critical medical treatment for the millions of individuals worldwide with celiac disease (celiac disease), an autoimmune condition for which no other therapy is currently available" (1). That part is true. However, she then cites a study in which patients with celiac disease followed a gluten-free diet for an average of between 0 and 8.2 years and showed higher serum levels of mercury than either healthy controls eating a regular diet, or patients with celiac disease who were not following a gluten-free diet (21). There are several important things wrong here. The first is that Dr. Reilly has assumed that what is happening with the treated celiac patients may reasonably be assumed to be happening to those with NCGS who choose to follow a gluten-free diet. However, as she has so adroitly pointed out, people with celiac disease are different from those with NCGS. Thus, as was stated in the study of mercury and celiac disease that she cited (21), a person with celiac disease might have a genetic propensity for increased mercury absorption. Or they might experience a resurgence of those portions of the intestinal villi that are more likely to offer the primary point at which mercury is absorbed, or they might be more inclined to have mercury amalgam fillings that are degraded and absorbed due to grinding one's teeth, or chewing gum (21) or perhaps gastro-esophageal reflux is a factor in the degradation of mercury amalgam fillings. The authors of this study of mercury and celiac disease also acknowledge that their report is limited by the small number of participants. Dr. Reilly, on the other hand, fails to mention that only a small number of treated celiac patients participated in this study - only twenty of them. Neither does she seem to recognize that the study's results cannot legitimately be generalized from celiac patients on a gluten-free diet, to the non-celiac gluten sensitive population who may choose to avoid gluten. Further research might bridge that gap, but the study she cited does not (21) and such results should not be used to suggest a generalized risk that may be exclusive to those with celiac disease.

The same study also seems to include treated celiac patients who are very new to the diet but have shown diminished tissue transglutaminase antibody levels (21). The average duration of the gluten free diet is 8.2 years, but with a deviation of up to 8.2 years. It is difficult to understand how this could mean anything else. I have contacted the lead author for clarification and have not yet received a response.

With respect to high levels of inorganic arsenic in rice pablum, the celiac and gluten sensitive community has been aware of this problem since the 2009 publication of several articles, both in the popular and peer-reviewed scientific literature, arising out of studies conducted by professor Andy Meharg and his students the previous year (22). They found that samples of several brands of rice pablum purchased at supermarkets, commonly fed to babies, contained high levels of arsenic. Here in the Journal of Gluten Sensitivity, we also published a warning article (23). Some members of the same research group that exposed this problem with rice pablum have also published data showing that phosphorus fertilizer can mitigate uptake of arsenic in wheat (24). We continue to hope that rice farming practices will be similarly investigated and best practices will soon be prescribed for rice farmers, but Dr. Reilly has raised an important point here. Rice consumption should be limited by everyone, including those following a gluten-free diet.

Reilly has also asserted that "there are no data supporting the presumed health benefits of a GFD" (1). This bold statement is followed by a heading that reads "Fiction: Gluten is toxic", then " There are no data to support the theory of an intrinsically toxic property of gluten" (1). Yet gliadins have also been demonstrated to damage a variety of tissue cells. In an experiment conducted by Hudson and colleagues, simple exposure to this sub-group of proteins from wheat gluten resulted in damage to several lines of embryonic cells (25). Similarly, Doherty and colleagues showed that many persons who are fed large amounts of gluten will develop villous damage or other intestinal damage, even in the absence of celiac disease (26). Some gluten proteins will cause damage to a variety of cell lines, and people fed large amounts of gluten will experience intestinal damage, yet Dr. Reilly claims that there are no data to support what she calls the "fiction" that gluten is toxic (1).

Reilly also decries the higher fat content of the gluten-free diet. But dietary fats combine to make up a huge topic. Some promote inflammation. Others have anti-inflammatory properties. Some must be used as energy or they will prompt the liver to produce ketone bodies. These latter offer alternative fuels for the brain in the context of insulin resistance (27). Condemning its high fat content is a little like lumping all gluten-free diets into one group. It is a gross over-simplification that draws into question the writer's competence in the realm of Dietetics.

The same can be said about Reilly's identification of iron deficiency as the result of avoiding gluten grains. Until we have a better understanding of the proportions of the various minerals that are irreversibly bound by phytates and phenols in the human gastrointestinal tract, blaming gluten grain avoidance for iron deficiency in humans is, at best, inaccurate. While she does mention that many of these nutrients we will fail to get from gluten free foods are simply fortifications that have been added to processed, gluten-containing foods, she has failed to recognize or discuss the mineral binding and wasting that ensues from eating these foods and additives together.

Similarly, while some B vitamins are plentiful in processed, gluten-containing grains, others are not. However, the same B vitamins are abundantly available in other common food sources that do not contain the anti-nutrients common to cereal grains. Such deficiencies are not the result of a gluten free diet so much as they are the result of a poorly balanced diet, which can happen regardless of gluten exclusion.

Reilly goes on to admonish those who are at risk of developing celiac disease not to undertake a gluten-free diet "without first testing for celiac disease" (1). This is spoken like a person who is intimately familiar with the medical system and would have little or no difficulty getting adequate testing to rule out celiac disease on request. She has probably not spent much of the previous decade or so repeatedly undergoing repeated rounds of the same useless tests, such as barium swallow X-rays, barium enema X-rays along with repeated, often unnecessary, courses of various antibiotics, multiple courses of drugs to treat ulcers that fail to show up on the aforementioned tests, and taking supplements or drugs to correct blood test abnormalities, without considering the potential underlying causes. And none of the above strategies are likely to ever suggest celiac disease. Yet these are the stock-in -trade of the general practitioner who is often reluctant to refer to gastrointestinal specialists. This reluctance frequently escalates when the above symptoms are accompanied by psychiatric and/or neurological complaints, although such symptoms are reported in between 51% and 73% of newly diagnosed celiac patients (7, 8) and some cases of psychosis can be attributed to gluten intake alone (18, 19, 28). In the face of such evidence, the claim that gluten fractions are not toxic seems almost laughable. Yet her polemic "commentary" has spawned quite a number of spin-off articles that condemn the gluten-free diet as a fad or a hoax, and many innocent victims and their families continue to suffer from the psychiatric, neurological, and other extra-intestinal manifestations of non-celiac gluten sensitivity or celiac disease. I frequently observe school children with diagnosed learning disabilities who make huge strides forward when on a gluten free diet. And the explanation is really quite simple (29). And I am saddened by the certitude with which this diet is condemned by otherwise reasonable people.

Historically, the GFD has been contentious since it was introduced in 1937, when Dr. W.K. Dicke first began to treat his celiac patients with it. One may wonder why it has stirred so much controversy. I continue to be shocked when I read opinion articles such as Dr. Reilly's when they are included in peer-reviewed publications. I am not surprised by the many follow-up articles in the popular press that condemn the gluten free diet. This is the same resistance that I witnessed almost a quarter of a century ago, when I was diagnosed with celiac disease. I'm left wondering why so many supposedly objective professionals are so quick to oppose a diet that offers benefits to people with a wide range of maladies, many of which are, otherwise untreatable. What could motivate these vehement critics? I just don't understand.

Sources:
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