Celiac.com 07/29/2017 - "So what did you eat over there?"

I had only been back for a few days from a year-long deployment overseas and it seemed to me my friends and family were all fascinated that I went to war on a gluten free (gluten-free) diet. They all knew I was gluten-free. I had been strictly adhering to the diet for well over a decade, and many of them had worried about my health in addition to my safety and well-being. In truth, it had been overwhelming at times. The military complex was not set up to cater to food allergies (or auto-immune responses) and I frequently had to order food to maintain a gluten-free existence. Besides the extra cost, the logistics of getting gluten-free food into Afghanistan were mind boggling. Yet, I was often seen around Kandahar with a gluten-free roll in my cargo pocket, trying my best not to crush it to pieces with the barrel of my loaded M16.

As a Captain in the United States Army I had the resources to make this happen. I would demand meetings with dining facility mangers, and would pay out of pocket the high shipping cost of getting gluten-free food to Kandahar (a process that took so long the food often arrived moldy or destroyed). I would contact home and was sent additional gluten-free foods from family, friends, and co-workers. My diet, which became primarily salad and packaged gluten-free food, turned out to be sustainable over the course of the deployment. Of course, it was not without its struggles, and in retrospect a lot of the hardship could have been avoided if the military would recognize a need to cater to special diets, in the same way it does for Kosher or Vegetarian meals.

So why doesn't the military provide a gluten-free alternative? In my opinion it is because no one is asking for it. While overseas I attempted to find other gluten-free dieters, and celiacs, to reach out to them and document their struggles. I found over fifteen others simply by asking around Kandahar. Yet, even if I could prove that hundreds of people needed a gluten-free diet, it would be fruitless since many of them are too afraid of a discharge to bring up the dietary requirement. Part of this fear is unfounded since celiac disease is not specifically listed in AR 40-501 (The Standards of Medical Fitness); but, part of it is founded since "Nutritional Deficiencies" are listed and can be cause for rejection from service. Not wanting to risk their careers, these soldiers simply sacrifice their health.

This risk that the military may ban celiacs is simply acceptance of the quiet suffering of these service members. It is naïve to think otherwise. Should a hot shot superior read my story, throw me out and ban other celiacs (which, albeit unlikely, is possible) all they would be doing is sending a message to others with special diets to keep their mouths shut (pun intended). A more logical approach would be to take simple steps such as listing allergens from the 2004 Food Allergen Labeling and Protection Act on dining facility food. This would go a long way toward improving the lives and health of service members worldwide. Yet, if no one complains then the Army can easily determine it does not need to change. While a few of us may make waves from time to time it may very well take a literal act of congress before a gluten-free- MRE (Meal Ready to Eat) or gluten-free foods are a viable option for service members.

Since my memoir, Gluten Free in Afghanistan, was published. many service members have contacted me to share their experiences. Only one has said she was discharged due to celiac disease. Most are still serving after being diagnosed by the Army. Many of them reported similar experiences to my own; which is being sent to a Medical Evaluation Board (MEB), being asked if we could figure out what to eat at the dining facility, and (after answering yes) being sent on our way to rejoin the ranks. In this light, being able to serve is certainly a possibility and one that has been done many times; but, if you are considering military service or know a celiac who is, understanding what you are getting into should be a far greater concern than whether you can or cannot get into the service.
If you are not in the service, you may want to consider writing your Senators or Congressman to encourage including gluten-free options for our brave men and women overseas (much in the same way the military offers both Kosher and Vegetarian alternatives). While I have returned from my tour and am once again comfortably eating gluten-free, many of our service members will continue to serve abroad for years to come and could use a gluten-free source of food.

As for my year long deployment, I chronicled my gluten-free adventure for three main reasons. First, my overall mission was to increase awareness and promote acceptance of the gluten-free diet and lifestyle. Second, to provide an inspirational guide to all of those who feel they have struggled with their special diet, gluten-free or otherwise. And, finally, to draw attention to our service members who need these accommodations to thrive. Being at war and on a gluten free diet is a distinct hardship, and if you know what you are getting into you understand there's no easy meal.

Celiac.com 07/22/2017 - In 1978 Virginia Slims' magazine advertising spouted "You've Come A Long Way Baby". Well, in 2011 "WE" celiac/DH people can express those same words when talking about how far we have travelled since I was diagnosed as a brittle celiac/DH person 16 years ago. If the people with peanut allergies can become well known, so can celiac people!

DID YOU KNOW: That 16 years ago gluten free foods were difficult to find, and upon finding the small frost-bitten white-gummy loaf of bread, which was even more expensive than it is today, one had to scrape it off the roof of your mouth with your tongue and chew!

I also remember trying to make a gluten free loaf of bread in our bread maker and having it turn out smaller than when it went in. My husband had to get it out of the container with a screw driver! Now we buy a bread mix which is gluten free, good, and when sliced thin tastes like the real thing!

You are the consumer. You have a right to ask questions. Don't go back to a restaurant or store that has "claimed" to have gluten free food or baking if you have suffered with an outbreak of dermatitis herpetiformis or abdominal pain after eating their food. I find that, with dermatitis herpetiformis, I know within the first 24 hours if I have ingested gluten. I was unaware, as a new celiac, that "Wheat Free" and "Gluten Free" do not mean the same thing. I now watch for the logo on boxes; the picture of wheat with a line crossing it out, meaning there is definitely no gluten in that product.

I wanted to have my very first '"DID YOU KNOW" Column to be centered around my favorite subject - food! I am hoping that readers will feel free to write to me at the 'Journal of Gluten Sensitivity' and offer your suggestions with regard to products you have come across in your search for "yummy" gluten free foods. I would also welcome hearing about restaurants and chain grocery stores that you want to recommend to fellow celiac people. Networking is the best way to glean information.

I also appreciate being corrected. When you provide me with information we all benefit. I want to hear from you, care of the magazine, about titles you would like to see covered. I have files on "The FDA'S Labeling Proposal", " current statistics", "cross-contamination" and web sites that won't grab you and suck you under}. I also have files on "dermatitis herpetiformis - helpful information I learned the hard way", " information about connective tissue disease", "dental care", "myths and facts"," current news/current events"," vitamins and minerals for the celiac", "other diseases that can affect the person with celiac disease", and my favorite, "names of gluten free products that taste like the real thing". They are out there. { And I don't get a kick-back" on products I tell you are too good to pass up!}

DID YOU KNOW? That Domino's Pizza were not the first Pizza Chain to advertise that they have a gluten free pizza crust? As far back as March 12, 2008, according to the Pizza Pizza www.pizzapizza.ca web site, they were the first Canadian pizza chain that advertised that their 50 Greater Toronto area restaurant locations offered a gluten free crust and numerous gluten free toppings as a pilot project. Big problem! As of November 6, 2012 they opened their 13th location in Montreal. Too far away for dine-in, and too far for their take-out service!

Domino's Pizza's based in Ann Arbor, Michigan, indicated it was the first national delivery chain to provide the choice of gluten free crusts with its pizzas. According to the PMQ Pizza Magazine, Pizza Hut, part of Yum! Brands (YUM) was the largest pizza seller in the U.S., followed by Domino's and Papa John's (PZA) at number three. All told, the magazine says pizza in 2010 was a 35 billion business in the 50 states. BUT, "Did You Know" that Domino's indicate that "Gluten avoiders should be aware that the crust will be prepared in the same kitchen as the regular gluten-containing crusts, so some risk of gluten exposure will remain."

Even so, the NFCA said it was happy to have Domino's "on board". As of Friday, May 12, 2012 Domino's pizza was still waiting for the U.S. Food and Drug Administration to resolve the issue of safe threshold levels of gluten for food labeling.

"Happy Joe's Pizza", chain-store pizza restaurants have a small size gluten-free pizza crust that is very good according to my U.S. relatives who are also gluten intolerant.

The ACDA (American Celiac Disease Alliance) firmly believes that the standard adopted by the FDA must be substantiated by evidence-based research, with limits established through double-blind, randomized trials. Research conducted in 2007 supports setting the gluten-free standard at the proposed level. There are few studies assessing toxicity and safety of gluten exposure and none published thus far which demonstrate safe levels for individuals with celiac disease. [ACDA comments on FDA's labeling proposal.]

Does this make sense to you? We should be aware if the crust will be prepared in the same kitchen as the regular gluten-containing crusts, so some risk of gluten exposure will remain. This reminds me of ordering a Caesar salad, minus the croutons, in a well-known restaurant chain. After considerable questioning I found out that the waiter just took the croutons out of the Caesar salad! I am extremely sensitive to just a few crumbs of gluten. What is the use of our family buying two toasters to avoid cross-contamination only to have a waiter scoop out the croutons before serving me?

"Oats serve as a prime example in support of the FDA position in the U.S.A." {ACDA comments on the FDA's labeling proposal}. "Oats does not contain the gliadin protein and should be safe for celiac consumers. However, grain standards for the United States allow a set percentage of foreign grains to be present in packages of single name grains. By definition, then, oats may contain up to 25 percent of wild oats and other grains for which standards have been established under the United States Grain Standards Act. Research has shown, and the FDA acknowledges, that regular oats pose a risk to celiac consumers due to cross-contamination."

I was blown away when I read on the American Celiac Disease Alliance site that given the manner in which grain crops are rotated in the U.S., it is likely that similar contamination issues will arise with regard to other inherently gluten free grains. In fact, a recent study found that among 22 samples of inherently gluten-free grains, seeds and flour, seven (22%) exceeded the proposed FDA standard of

Additionally, the FDA itself has found that "qualifying language is confusing to consumers". {You can say that again!} "This approach eliminates the need for consumers to differentiate among products that are inherently gluten-free foods and those which are not. It will also eliminate the use of other statements on products such as 'made with gluten-free ingredients,' which can be misleading. Finally, it will, in our view, simplify the education process for patients and the public at large." (ACDA comments on FDA labeling proposal)

Cross-Contamination will be attacked in a later column.

The ACDA implored the FDA to consider the following: "It takes an individual, on average, six years of being ill, of bouncing from doctor to doctor before being properly diagnosed with celiac disease. Gluten-free foods do not undergo years of safety testing before going on the market like medications. Each and every day, celiac consumers are placed at risk when trying to determine if the foods intended to maintain their health are safe. They have only the clarity and accuracy of the labeling on which to rely. It is a heavy burden, but one that will be eased dramatically with the completion of this rule making."

An excellent web site entitled 'The Celiac Scene, Guides for the Gluten Free' has a seemingly limitless number of chain restaurants throughout Canada and the United States that have a gluten free menu. Some of their gluten free menus are small, but growing. The site even has maps that are updated regularly. You can press on the MAP Icon to find out where to locate the celiac endorsed restaurants and chains throughout North America. I was really happy to find the "Celiac Scene" web site! It is owned, operated and maintained by people with celiac disease themselves. Still, it states: "Consider them a guide, not a guarantee." This seems reasonable given the number of restaurant chains that are listed and the recalls that happen regularly.

In December 2011 there was a recall of the Metro Grocers' irresistible gluten free Honey-Nut O's cereal and Apple Cinnamon O's cereal because of gluten.

On a happier note Loblaws and President's choice have produced a new "Recipes to Riches" cookie product. The product labeling indicates that the product is gluten free. To assure this claim, the product has been made under strict processing conditions. Every precaution has been taken to ensure that no gluten containing ingredients are included and all possible cross contamination is eliminated. Another great boxed mix is King Arthur Scones and cookie Mix, available in the United States and Canada. Follow the directions and they will be gone the first day! King Arthur also has a box flour, sold in the U.S.A. and Canada. You can substitute this flour in your regular recipes, use smaller pans, reduce your cooking time and you won't be digging them out of your muffin tins!

DID YOU KNOW? That Betty Crocker now has a gluten free Bisquick? You can make pancakes, waffles, pizza base, meat pie topping, scones, and I even tried some muffins!
Fast-food restaurants began to offer gluten-free foods as part of their regular menus as early as 2006. Each restaurant offers gluten free food based on their own criteria as there is no universal standard. {"What Fast Foods Are Gluten Free? Ehow.com }

NOTE: "based on their own criteria as there is no universal standard". McDonald's provides food-allergy information on its website (see link in Resources) as do many other fast-food restaurants. The In-N-Out chain is the most gluten-free friendly fast-food restaurant, while McDonald's has the least number of choices that are gluten-free. Other fast food restaurants also vary in the number of gluten-free foods they offer. The Olive Garden has a separate menu for the celiac but it is slim pickings. The majority of foods offered at fast-food restaurants that are gluten-free consist of salads, ice cream products and some of the "side" dishes such as those made from potatoes. Keep in mind the "Buyer Beware" rule still applies. French fries are often coated with flour, like the wonderful Costco and McDonald's French fries, some ice creams even contain flour. If you don't ask, they won't tell you!

Even gluten free food can vary by fast food restaurant; for example, while french fries at Sonic are gluten-free, those from McDonald's are not. You are the checker. Many of them have a black book or a binder with lists of ingredients for the products they provide. To be safe, check the allergy information first.

THE CELIAC SCENE also has a sheet on " How to start a conversation on celiac friendly dining". It is really good, though I cannot imagine myself asking my waiter or server "Did you wash your hands/change gloves/change aprons before or in between preparing regular food?" We should, you know, and we have every right to question our server and the kitchen staff. Remember, gluten is poison to us and we can become very ill ingesting it. Questions like "Could the finished product become contaminated with gluten while waiting to be served?" and "How do servers confirm with the kitchen that the order they are collecting from them is gluten-free?" and "How do servers confirm with the customer that the order they are providing is gluten free?" and "Will my food be prepared in an area separate from the regular flow of the kitchen?" and "How do you ensure that all utensils used in preparing my food are free from traces of gluten?" There are a lot more questions on The Celiac Scene Guide for the Gluten Free, and if I can find it on the world wide web anyone can!

DID YOU KNOW?: With regard to Domino's gluten free pizza, Yahoo Finance has a web site where you get the real story. The crust is appropriate for those with MILD gluten sensitivity, "But it is not recommended for people who have celiac disease." The NFCA says that one out of every 133 Americans has celiac disease or about 3 million Americans in all. Another 18 million have a less serious "sensitivity" to gluten, the organization says. Gluten is found in wheat, barley and rye. Celiac disease is a condition in which the immune system responds to gluten intake by damaging the small intestine. That can inhibit the absorption of various nutrients.

GLUTEN AVOIDERS should be aware that the crust will be prepared in the same kitchen as the regular gluten-containing crusts, so some risk of gluten exposure will remain, the company said. Even so, the NFCA said it was happy to have Domino's on board. They may be "on board" but according to me they are going to sink if they do not make some rapid changes. I don't want to write any more about Domino's Pizza, and I'm sure you don't want to hear any more about it unless some big changes are made.

Next time I'll write about excellent recipe books for the celiac. My cupboard is full! And a reminder from me, those lovely gluten free cakes on the glass covered bakery shelves - I urge you to ask how long they have been there. Some of those cakes, in certain bakeries, have been sitting in that case for a month, and the server is just using a piece of wax coated paper to box up bakery products, while passing them over the celiac baking. How do I know? My husband and I did a little checking during the summer and the lovely little banana sponge bomb was on that bakery shelf for a month.. Ick!

Cheers! Until next time.

Celiac.com 07/14/2017 - Dietary phosphorus occurs naturally in foods like dairy products, animal meats and legumes. The institute of Medicine recommended dietary allowance (RDA) is 700 mg/day while the NHANES data indicates that the typical American consumes more than twice that every day.

Phosphorus is considered an essential nutrient but it is increasingly being added to processed foods via additives (anti-caking agents to preserve moisture and color) or as a stabilizer, leavening agent or acidifier. Since it is not required to be listed on the label, it is difficult to know how much is being added and consumed. High levels of phosphorus is now being considered an independent predictive factor in mortality and morbidity from cardiovascular, kidney, and osteoporosis disorders.

People with celiac disease need to be considering how many processed foods they are consuming as food manufacturers continue to offer increasing numbers of gluten-free processed foods. According to Packaged Facts 2012, breads, cereals and grains comprise 53% gluten-free purchases; snack foods 44%; sweet baked goods (cookies) 30%; frozen/refrigerated meals and entrees 27%; baking mixes 26% and packaged dinner/side dishes 24%.

Phosphates in the form of food additives contribute to the increasing health implications when not consuming a fresh foods diet. Avoiding carbonated beverages is the best way to reduce phosphorus levels in the diet. Aside from that, the person with celiac disease must pay attention to ingredient statements that may include these declarations: tricalcium phosphate, trimagnesium phosphate, disodium phosphate, dipotassium phosphate. According to current regulations, these ingredients are safe when used in good manufacturing processes but the more one consumes prepared foods, the more elevated the blood phosphorus levels can rise.

The Institute of Food Technology in its December 2012 journal states," It has been difficult for consumers to find gluten-free alternatives that taste good and have desirable texture properties. Consequently, manufacturers are looking for different ingredient solutions that will address these problems". Phosphate additives have provided that solution without consumers being aware of the health implications.

Yes, the food world offers a wider array of gluten-free foods than ever before but just because it states "gluten-free" on the label does not mean it is a healthy food for everyday consumption. Remember: Fresh is Best!

Here is a guide I use to help those choosing processed foods to be wiser consumers:

• Baked Goods: cake mixes, donuts, refrigerated dough = pyrophosphates for leavening and dough "improver".
• Beverages: phosphoric acid in colas for acidulant, pyrophosphate in chocolate milk to suspend cocoa, pyrophosphate in buttermilk for protein dispersion, tricalcium phosphate in orange juice for fortification, tetrasodium phospahte in strawberry flavored milk to bind iron to pink color.
• Cereals: phosphate in dry cereals to aid flow through extruder and fortification.
• 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: tripolyphosphate for injections into ham, corned beef, sausage, franks, bologna, roast beef for moisture and color development.
• Nutrition Bars & Meal Replacement Drinks: phosphates for fortification and microbiological stability.
• Potatoes: phosphate in baked potato chips to create bubbles on surface, and pyrophosphate in French fries, hash browns, potato flakes to inhibit iron induced blackening.
• Poultry: tripolyphosphate for moisture and removal of Salmonella and Campylobacter bacterial pathogens.
• Puddings & Cheesecakes: phosphate to develop thickened texture.
• Seafood: tripolyphosphate in shrimp for mechanical peeling, pyrophosphate in canned tuna and crab to stabilize color and crystals, surimi ("crab/sea sticks") triphosphate and pyrophosphate as cryoprotectant to protein.

For those not having food composition tables available, here is a comparison of common snack foods to show how phosphorus levels quickly can add up. Many food companies do not provide analysis information on phosphorus because it is not required for the nutrition label.

• Hershey Bar with Almonds - 116 mg
• Cola Beverage (12 oz) - 44 mg
• M&M Peanuts (1.74 oz pkg) - 93 mg
• Yogurt (1 cup) - 300 mg
• Total Cereal (1 cup) General Mills - 200 mg
• Peanuts (1 oz) - 150 mg
• Apple, raw (1 med) - 10 mg

Celiac.com 07/06/2017 - Each New Year you will find a plethora of articles on weight loss. Unfortunately, for those with celiac disease, weight loss is not always an issue, but for some the opposite is true. Though much false information in the medical community remains, such as "you must be underweight to have celiac disease", there are many who are overweight. Whether you want to gain or lose weight, they have one thing in common, the need for nutritious food, and food that does not cause inflammation in the body.

If you look at autoimmune diseases, in general, you will notice they have one thing in common, inflammation. Celiac disease – inflammation of the small intestines; multiple sclerosis – inflammation of the central nervous system, Grave's disease – inflammation of the thyroid gland; arthritis – inflammation of the joint tissues and cartilage; Crohn's disease – inflammation of the digestive tract; Alzheimer's disease – inflammation of the brain; transverse myelitis – inflammation of the spinal cord; etc.

When we consume foods that we are either allergic to or sensitive to, our white blood cells release toxic chemicals to fight off what it perceives as foreign bodies resulting in inflammation. If our bodies are too busy fighting off inflammation from a non-optimal diet or stress, they do not have enough resources to fight the real bad guys.

Some of the foods known to fight or prevent inflammation are spices such as turmeric, curry, cinnamon, ginger, and garlic; tropical fruit such as coconut, pineapple (contains a natural antihistamine), and papaya; green tea; fish oil and fish; and a wide variety of colorful vegetables such as spinach, kale, broccoli, cauliflower, kelp, red peppers, sweet potatoes, and cabbage.

Research shows that omega-3's are not only known to reduce inflammation, but it may lower the risk of chronic diseases such as arthritis, cancer and heart disease(1). Because our bodies cannot make omega-3 fatty acids we must obtain them from food or supplements. If your doctor has recommended that you take an omega-3 supplement or increase omega-3 in your diet, it is important that you know the two main types. Omega-3's which are marine-based (fish and fish oil) contain EPA and DHA, where the other contains ALA. ALA omega-3 may be obtained from soybean, canola, and flax seed oils, ground flax seed, and walnuts, as well as kale, spinach, Brussels sprouts, and leafy greens. Though our body does not make omega-3's, it does partially convert ALA to DHA and EPA. Per Harvard School of Public Health, we do not know which, if either, is more beneficial (2,3). Research does show that EPA and DHA do reduce the risk of heart disease in older adults.(4) When ALA is added to our diet it is known to reduce the risk of breast cancer and prostate cancer, as it helps your body metabolize estrogens into a safer form.

You may already be aware of the fact that aloe vera contains a gel-like substance that is known to heal. (As a side note, aloe vera products sometimes contain laytex.) Flax seeds contain the same property. It is also high in omega-3, though yellow flax seeds are lower. Brown flax seeds have the most health benefits.

Another popular superfood is chia seeds. It does not contain the same properties as flax, however, chia seeds provide similar benefits as flax, and they do not need to be ground in order to reap those benefits. Chia benefits include fiber, calcium, antioxidants, protein, and more.

Fiber is known to make one feel full, however, both flax and chia seeds absorb quite a bit of liquid, creating the feeling of fullness for a longer period of time than many other fibers. This is a great and healthy way to lose weight.

A misconception about losing weight is to skip meals. When you do this it throws your blood sugar levels out of whack. Some believe this results in weight gain, or at least in no loss. Minimally, it is unhealthy. What does make sense is that if you eat more often such as 4 – 5 times a day, and on a regular schedule, your blood sugar levels maintain balance and your body recognizes that it will receive more food soon, which may prevent it from going into a starvation mode, storing fat. The bottom line is always calorie intake, though. Choose wisely, and avoid the use of refined sugar and artificial sweeteners, as this increases acidity in the body, resulting in inflammation. When chronic inflammation is present in the body it depresses the immune system and creates disease, even tumors.(2) Inflammation really is the precursor to disease.

For those with celiac disease needing to gain weight, note that it may take several months to up to a year before your gut is healed enough to absorb nutrients properly. Meanwhile, check the ingredients and foods that you consume to ensure they are truly gluten-free. Due to the lack of labeling laws in the U.S., a food labeled gluten-free may still contain a small amount of gluten. Consume a high calorie diet with healthy fats such as avocado,coconut oil, high calorie nuts such as walnuts and pecans, nut butters, and if dairy-tolerant, cream cheese. Add avocado to your sandwiches, healthy oil to protein shakes and smoothies; consume high carbohydrates such as potatoes; and snack between meals.

Individuals who need to avoid dairy may find it difficult at times. There are a number of gluten-free, dairy-free substitutes on the market now. If you are soy and corn intolerant, as well, you may find it difficult to find a dairy-free substitute for butter. A small percentage of dairy intolerant individuals may tolerate goat's milk; and some even tolerate ghee (clarified butter). Because a minute amount of dairy protein may remain in ghee, and because goat's milk is considered dairy, it is best to be tested for food allergies if you suspect a dairy allergy, prior to consuming the above.

Previous studies on food allergies focused on antibodies (proteins that attack foreign substances and sometimes even food) found in the blood. In a preliminary study performed by the University of Osio, Norway, it was discovered that food-related antibodies may end up in the gut. When the body mistakes a food for a foreign matter, it creates IgE antibodies (Immunoglobin E), which creates a chain reaction of symptoms. Though the study was performed on those with rheumatoid arthritis (RA), in the participants' intestinal fluid they found antibodies to the following foods: cow's milk, hen, cereal, eggs, codfish, and pork, at higher levels than in non-RA patients.(5) Similar results may be found in those with celiac disease or gluten intolerance, even the general population. We will not know until additional studies are performed. It is definitely food for thought.

If you have any type of unexplained symptoms, that medical professionals have not been able to diagnose, consider being tested for other food intolerances or allergies, besides gluten. Consuming foods that cause your immune system to react will only create additional inflammation. There has been much talk that many individuals have had positive results from using Cyrex Labs. You cannot do these tests by mail, as someone must draw your blood. However Cyrex Labs has a list of doctors who will provide this service.

If you are not quite sure what you are allergic or sensitive to, another option to consider is an allergy elimination diet. For one month eat only meat, fish, fruit, vegetables, basically a caveman diet, quite a bit stricter than the Paleo Diet. (Definitely check with your doctor first.) Then introduce one food at a time back into your diet. Note that food allergy reactions may be immediate or within a couple of days, where a sensitivity may take longer to show up.(6) This is also a great way to lose weight.

If you are new to the gluten-free diet, make sure to introduce new foods, especially gluten free grains, one at the time. Consume the item a few times within a couple of days and wait for 2-4 days and take note whether you have a reaction to it. The reaction may be as complicated as hives, dermatitis herpetiformis, or digestive issues; or as simple as a bad night's sleep or slight bloating. Note that some people may not present any symptoms, even to gluten, and still have celiac disease. The above is referenced for food allergies and sensitivities only. The best advice for anyone who is gluten intolerant is to strictly adhere to the gluten-free diet. One study shows that only 52.1% of those with celiac disease adhere to a gluten-free diet.(7)

What will your New Year's resolution be now?

References:
1. Omega-3 Fatty Acids University of Maryland Medical System http://www.umm.edu/altmed/articles/omrga-3-000316.htm  (Accessed December 6, 2012).
2. Arizona Advanced Medicine (Accessed December 7, 2012).
3. The Nutrition Source, Ask the Expert: Omega-2 Fatty Acids Harvard School of Public Health http://www.hsph.harvard.edu/nutritionsource/questions/omega-3/index.html  (Accessed December 6, 2012).
4. Circulating long-chain w-3 fatty acids and incidence of congestive heart failure in older adults: the cardiovascular health study: a cohort study. PubMed https://pubmed.ncbi.nlm.nih.gov/21810709/  (Accessed December 6, 2012).
5. Denise Lynn Mann Rheumatoid Arthritis Diet: RA and Food Allergies (arthritistoday.org - Accessed December 7, 2012).
6. Dr. Jonathan Brostoff, M.D. Food Allergies and Food Intolerance: The Complete Guide to Their Identification and Treatment (2000)
7. Talluri SK, Besur S, Talluri J, Department of Internal Medicine, McLaren-MSU Internal Medicine Residency Program, Flint, MI - A Population-Based Survey of Celiac Disease in the United States http://www.cdc.gov/nchs/events/2012nchs/poster_abstracts.htm#abstract74  (Accessed December 7, 2012).

Celiac.com 06/30/2017 - Dear attending physician: If you are reading this it is because your patient either expects you to refuse or you have refused to test them for celiac disease. You may believe, in keeping with prior training, that this patient does not display the signs or symptoms associated with celiac disease. However, the symptom complex of celiac disease has recently undergone dramatic changes, beginning with the understanding that celiac disease is a systemic, rather than an intestinal ailment. World renowned researchers have weighed in on this issue, with peer reviewed reports that repeatedly establish the protean manifestations of celiac disease. They defy prior algorithms for symptom assessment toward diagnosing celiac disease. In the past, undiagnosed celiac patients were often identified as asymptomatic because their symptoms were simply not diarrhea, abdominal bloating, and muscle wasting. However, the Celiac Disease Center at the University of Chicago lists more than 300 presenting symptoms of celiac disease (1). The same group also offers a list of symptoms that demonstrate the wide range of apparently unrelated symptoms that can indicate celiac disease, only the first two of which represent these classical symptoms (2).

• Recurring abdominal bloating and pain
• Chronic or recurrent diarrhea
• Constipation
• Nausea or emesis
• Liver and biliary tract disorders (increased serum transaminases, primary sclerosing cholangitis)
• Weight loss
• Pale, foul-smelling stool
• Iron-deficiency anemia unresponsive to iron therapy
• Fatigue
• Failure to thrive or short stature
• Delayed puberty
• Arthralgia
• Tingling numbness in the legs
• Pale sores inside the mouth
• Dermatitis herpetiformis
• Abnormal dentition (tooth discoloration, loss of enamel)
• Unexplained infertility or recurrent miscarriage
• Osteopenia or osteoporosis
• Peripheral neuropathy
• Psychiatric disorders (anxiety or depression)

Please remember that any one or more of the above symptoms and/or ailments may indicate untreated celiac disease, so testing for celiac disease is an important, inexpensive step toward assisting a patient to resolve these troubling, sometimes debilitating, symptoms.

Overweight and obesity may also indicate underlying celiac disease. Today's affluence and accompanying food surpluses permit people who are not absorbing nutrients efficiently to eat enough to more than compensate for otherwise calorically deficient diets. Thus, only a minority of celiac disease cases present with classical symptoms in most of the first world. In fact, some reports indicate that overweight patients with celiac disease are as common as those who are underweight ( 3, 4, 5). This is why researchers have long employed the iceberg metaphor to describe the mass of people with celiac disease. The vast majority these people with celiac disease remain undiagnosed (6). Until sensitive and specific serological screening tools became available, very few cases were diagnosed and celiac disease was erroneously considered rare.

In addition to alleviating quite a lot of human suffering, early detection offers some rather large economies for the health care system, as many of the more serious ailments that often befall those with untreated celiac disease may be averted through these inexpensive serological tests and subsequent prescription of a strict gluten free diet.

Prior to the therapeutic use of a gluten free diet, mortality was reported at 36% among 73 children with celiac disease (7). Admittedly, it is likely that these were the more serious cases and perhaps some cases of misdiagnosis. However, even as recently as 1989, adult celiac patients experienced almost double the early mortality rate seen in the general population (8), so an early diagnosis and treatment of celiac disease is not just helpful in mitigating current symptoms, it is a powerful form of preventive medicine that is coincidental to the appropriate diagnosis and treatment of celiac disease.

Let me expand on that last comment a little further. Chronic depression (9), ADHD (10), neurological (11) and neuromuscular disorders(12) treatment-resistant iron deficiency (13, 14), impaired lung function (15, 16) a variety of lymphomas including B cell and T cell (17, 18, 19) and adenocarcinomas (20, 21) dental enamel defects (22, 23) autoimmune thyroid disease (24, 25 ) autoimmunity in general (26) type 1 diabetes (27, 28) kidney disease (29) liver disease (30, 31) skin disease (32, 33) seizure disorders (34) gait disorders (35) obesity (36) fatigue (37) anxiety (38) infertility (39) osteoporosis (40) learning disorders (41, 42) aphasia (43) and many more such sequels to untreated celiac disease (44) impose an enormous economic burden on our health system and education system. This burden weighs on most levels of government, private insurance companies, families, and individuals. Much of this unnecessary cost is ultimately passed along to taxpayers and/or are incorporated into insurance premiums. We all pay.

And the human costs are even greater. Attention deficits and learning disabilities impose life-long inhibitions on success and are corrosive to self esteem. Depression robs us of individual, economic and social achievements, as well as denying us the day-to-day pleasures of life. Similarly, anxiety and infertility are socially isolating and heartbreaking, each in their own ways. Neurological and seizure disorders, including gait disorders, can inhibit our mobility and/or our safe function in this increasingly complex and fast-paced society. Impaired lung function can prohibit or interfere with normal, desirable activities ranging from pleasant walks, sports, and even having sex. Lymphomas and adenocarcinomas can have rapidly fatal consequences. The individual and familial consequences are often devastating. Type 1 diabetes tethers us to insulin injections and requires that we maintain a careful balance between carbohydrate intake and insulin injections. The challenges of this diet dwarfs the inconvenience of a gluten free diet, and a late celiac diagnosis may require that some people comply with both sets of dietary constraints. Skin disease can also exact an enormous social toll, and this is ignores the discomfort and embarrassment of constant itching and scratching, as well as the pain associated with the most common skin diseases connected to celiac disease. Similarly, obesity is not only socially excluding, it poses its own sets of health hazards and life shortening penalties. As osteoporosis becomes more and more common, we can see that society's increasing nutritional dependence on gluten grains may well have set the stage for this degenerative condition, often requiring painful and expensive joint replacement surgeries as our bones gradually crumble and shrink. The dramatic loss of our ability to produce intelligible speech, called aphasia, is by no means the least of this list. The horrific nightmare of being unable to speak to others and have them understand us has been the lived experience of at least one individual. His speech slowly returned after his celiac diagnosis and some time on a gluten free diet. Too many of us are not so lucky.

Many of us see ourselves, and our symptoms, in the many posts, blog comments, listservs and websites that discuss celiac disease. Yet outdated medial training can create barriers to patients seeking testing. However, given the above, peer reviewed data and expert opinions, it is difficult to imagine any reasonable argument for refusing to test a patient who requests serological testing for celiac disease. The cost is minimal and the potential benefits to those who are diagnosed, and our society, are enormous.

Current data suggest a prevalence of celiac disease in the general population at somewhere around 1%, based on serological testing for selective antibodies. However, newly emerging data suggest that a portion of the population that is at least six or seven times the size of the group with celiac disease mounts an innate immune response to gluten grains. The careful characterization of one pathway for activating intestinal inflammation by non-gluten components of these grains, leaves open the possibility of "gliadin-dependent signaling pathways that still remain to be characterized" (45).

Other forms of non-celiac gluten sensitivity, as signaled by IgG class antibodies against gliadin, are seen in 10% to 12% of the general population. Whether these segments of the population with non-celiac gluten sensitivity overlap or are distinct has yet to be determined, so it remains unclear whether they form 10% of our population, or as much as 19% of our culture. Finally, based on a new book by the world renowned pediatric gastroenterologist and allergist, Dr. Rodney Ford, titled Gluten: Zero Global, there is considerable evidence to suggest that, with their many other anti-nutrient, addictive, allergenic, and blood-glucose altering features, gluten grains are a questionable macronutrient food source for humans (46).

Thus, testing for non-celiac gluten sensitivity, may offer many of the benefits that testing for celiac disease offers. Your patient and I are asking that you heed the above data from your professional literature and the first dictum of your profession, by 'first doing no harm', and ordering testing for celiac disease and non-celiac gluten sensitivity.

Sincerely,
Dr. Ron Hoggan, Ed. D.

Sources:
1. http://www.cureceliacdisease.org/wp-content/uploads/2011/09/CDCFactSheets10_SymptomList.pdf
2. http://www.cureceliacdisease.org/medical-professionals/guide/symptoms
3. Dickey W, Kearney N. Overweight in celiac disease: prevalence, clinical characteristics, and effect of a gluten-free diet. Am J Gastroenterol. 2006 Oct;101(10):2356-9
4. Tucker E, Rostami K, Prabhakaran S, Al Dulaimi D. Patients with coeliac disease are increasingly overweight or obese on presentation. J Gastrointestin Liver Dis. 2012 Mar;21(1):11-5
5. Cheng J, Brar PS, Lee AR, Green PH. Body mass index in celiac disease: beneficial effect of a gluten-free diet. J Clin Gastroenterol. 2010 Apr;44(4):267-71.
6. Katz KD, Rashtak S, Lahr BD, Melton LJ 3rd, Krause PK, Maggi K, Talley NJ, Murray JA. Screening for celiac disease in a North American population: sequential serology and gastrointestinal symptoms. Am J Gastroenterol. 2011 Jul;106(7):1333-9. doi: 10.1038/ajg.2011.21. Epub 2011 Mar 1.
7. Hardwick C. 1989, as described in Holmes GKT. Non-malignant complications of coeliac disease. Acta Paediatr Suppl. 412: 68-75. 1996.
8. Logan RF, Rifkind EA, Turner ID, Ferguson A. Mortality in celiac disease. Gastroenterology. 1989 Aug;97(2):265-71.
9. Zipser RD, Farid M, Baisch D, Patel B, Patel D. Physician awareness of celiac disease: a need for further education. J Gen Intern Med. 2005 Jul;20(7):644-6.
10. ADHD (10),Niederhofer H. Association of attention-deficit/hyperactivity disorder and celiac disease: a brief report. Prim Care Companion CNS Disord. 2011;13(3).
11. neurological and neuromuscular disorders (11, 12,) Currie S, Hadjivassiliou M, Clark MJ, Sanders DS,
12. Wilkinson ID, Griffiths PD, Hoggard N. Should we be 'nervous' about coeliac disease? Brain abnormalities in patients with coeliac disease referred for neurological opinion. J Neurol Neurosurg Psychiatry. 2012 Dec;83(12):1216-1221.
13. Hadjivassiliou M, Chattopadhyay AK, Davies-Jones GA, Gibson A, Grünewald RA, Lobo AJ. Neuromuscular disorder as a presenting feature of coeliac disease. J Neurol Neurosurg Psychiatry. 1997 Dec;63(6):770-5.
14. Fayed SB, Aref MI, Fathy HM, Abd El Dayem SM, Emara NA, Maklof A, Shafik A.
Prevalence of celiac disease, Helicobacter pylori and gastroesophageal reflux in patients with refractory iron deficiency anemia. J Trop Pediatr. 2008 Feb;54(1):43-53.
15. Cekın AH, Cekın Y, Sezer C. Celiac disease prevalence in patients with iron deficiency anemia. Turk J Gastroenterol. 2012 Oct;23(5):490-5.
16. Robertson DA, Taylor N, Sidhu H, Britten A, Smith CL, Holdstock G. Pulmonary permeability in coeliac disease and inflammatory bowel disease. Digestion. 1989;42(2):98-103.
17. Edwards C, Williams A, Asquith P. Bronchopulmonary disease in coeliac patients. J Clin Pathol. 1985 Apr;38(4):361-7.
18. Bautista-Quach MA, Ake celiac disease, Chen M, Wang J. Gastrointestinal lymphomas: Morphology, immunophenotype and molecular features. J Gastrointest Oncol. 2012 Sep;3(3):209-25.
19. Leslie LA, Lebwohl B, Neugut AI, Gregory Mears J, Bhagat G, Green PH. Incidence of lymphoproliferative disorders in patients with celiac disease. Am J Hematol. 2012 Aug;87(8):754-9.
20. Elfström P, Granath F, Ekström Smedby K, Montgomery SM, Askling J, Ekbom A, Ludvigsson JF. Risk of lymphoproliferative malignancy in relation to small intestinal histopathology among patients with celiac disease. J Natl Cancer Inst.2011 Mar 2;103(5):436-44.
21. Benhammane H, El M'rabet FZ, Idrissi Serhouchni K, El Yousfi M, Charif I, Toughray I, Mellas N, Riffi Amarti A, Maazaz K, Ibrahimi SA, El Mesbahi O. Small bowel adenocarcinoma complicating coeliac disease: a report of three cases and the literature review. Case Rep Oncol Med. 2012;2012:935183.
22. Vecchio R, Marchese S, Gangemi P, Alongi G, Ferla F, Spataro C, Intagliata E. Laparoscopic treatment of mucinous adenocarcinoma of jejunum associated with celiac disease. Case report. G Chir. 2012 Apr;33(4):126-8.
23. El-Hodhod MA, El-Agouza IA, Abdel-Al H, Kabil NS, Bayomi KA. Screening for celiac disease in children with dental enamel defects. ISRN Pediatr. 2012;2012:763783.
24. Erriu M, Sanna S, Nucaro A, Orrù G, Garau V, Montaldo C. HLA-DQB1 Haplotypes and their Relation to Oral Signs Linked to Celiac Disease Diagnosis. Open Dent J. 2011;5:174-8.
25. Cats EA, Bertens AS, Veldink JH, van den Berg LH, van der Pol WL. Associated autoimmune diseases in patients with multifocal motor neuropathy and their family members. J Neurol. 2012 Jun;259(6):1137-41.
26. Bardella MT, Elli L, De Matteis S, Floriani I, Torri V, Piodi L. Autoimmune disorders in patients affected by celiac sprue and inflammatory bowel disease. Ann Med. 2009;41(2):139-43
27. Nass FR, Kotze LM, Nisihara RM, de Messias-Reason IT, Utiyama SR. Autoantibodies in relatives of celiac disease patients: a follow-up of 6-10 years. Arq Gastroenterol. 2012 Jul-Sep;49(3):199-203.
28. Saadah OI, Al-Agha AE, Al Nahdi HM, Bokhary RY, Bin Talib YY, Al-Mughales JA, Al Bokhari SM. Prevalence of celiac disease in children with type 1 diabetes mellitus screened by anti-tissue transglutaminase antibody from Western Saudi Arabia. Saudi Med J. 2012 May;33(5):541-6.
29. Van den Driessche A, Eenkhoorn V, Van Gaal L, De Block C. Type 1 diabetes and autoimmune polyglandular syndrome: a clinical review. Neth J Med. 2009 Dec;67(11):376-87.
30. Welander A, Prütz KG, Fored M, Ludvigsson JF. Increased risk of end-stage renal disease in individuals with coeliac disease. Gut. 2012 Jan;61(1):64-8.
31. Drastich P, Honsová E, Lodererová A, Jarešová M, Pekáriková A, Hoffmanová I, TuÄková L, Tlaskalová-Hogenová H, SpiÄák J, Sánchez D. Celiac disease markers in patients with liver diseases: A single center large scale screening study. World J Gastroenterol. 2012 Nov 21;18(43):6255-62.
32. Massironi S, Rossi RE, Fraquelli M, Bardella MT, Elli L, Maggioni M, Della Valle S, Spampatti MP, Colombo M, Conte D. Transient elastography in patients with celiac disease: a noninvasive method to detect liver involvement associated with celiac disease. Scand J Gastroenterol. 2012 Jun;47(6):640-8
33. Caproni M, Bonciolini V, D'Errico A, Antiga E, Fabbri P. Celiac disease and dermatologic manifestations: many skin clue to unfold gluten-sensitive enteropathy. Gastroenterol Res Pract. 2012;2012:952753.
34. Criado PR, Criado RF, Aoki V, Belda W Jr, Halpern I, Landman G, Vasconcellos C. Dermatitis herpetiformis: relevance of the physical examination to diagnosis suspicion. Can Fam Physician. 2012 Aug;58(8):843-7.
35. Maniar VP, Yadav SS, Gokhale YA. Intractable seizures and metabolic bone disease secondary to celiac disease. J Assoc Physicians India. 2010 Aug;58:512-5.
36. Hadjivassiliou M, Grünewald R, Sharrack B, Sanders D, Lobo A, Williamson C, Woodroofe N, Wood N, Davies-Jones A. Gluten ataxia in perspective: epidemiology, genetic susceptibility and clinical characteristics. Brain. 2003 Mar;126(Pt3):685-91.
37. Balamtekin N, Demir H, Baysoy G, Uslu N, Yüce A. Obesity in adolescents with celiac disease: two adolescents and two different presentations. Turk J Pediatr. 2011 May-Jun;53(3):314-6.
38. Greenfield JR, Samaras K. Evaluation of pituitary function in the fatigued patient: a review of 59 cases. Eur J Endocrinol. 2006 Jan;154(1):147-57
39. Smith DF, Gerdes LU. Meta-analysis on anxiety and depression in adult celiac disease. Acta Psychiatr Scand. 2012 Mar;125(3):189-93.
40. Choi JM, Lebwohl B, Wang J, Lee SK, Murray JA, Sauer MV, Green PH. Increased prevalence of celiac disease in patients with unexplained infertility in the United States. J Reprod Med. 2011 May-Jun;56(5-6):199-203.
41. Rastogi A, Bhadada SK, Bhansali A, Kochhar R, Santosh R. Celiac disease: A missed cause of metabolic bone disease. Indian J Endocrinol Metab. 2012 Sep;16(5):780-5
42. Knivsberg AM. Urine patterns, peptide levels and IgA/IgG antibodies to food proteins in children with dyslexia. Pediatr Rehabil. 1997 Jan-Mar;1(1):25-33.
43. Zelnik N, Pacht A, Obeid R, Lerner A. Range of neurologic disorders in patients with celiac disease. Pediatrics. 2004 Jun;113(6):1672-6.
44. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 43-1988. A 52-year-old man with persistent watery diarrhea and aphasia. N Engl J Med. 1988 Oct 27;319(17):1139-48.
45. Norström F, Sandström O, Lindholm L, Ivarsson A. A gluten-free diet effectively reduces symptoms and health care consumption in a Swedish celiac disease population. BMC Gastroenterol. 2012 Sep 17;12:125
46. Junker Y, Zeissig S, Kim SJ, Barisani D, Wieser H, Leffler DA, Zevallos V, Libermann TA, Dillon S, Freitag TL, Kelly CP, Schuppan D. Wheat amylase trypsin inhibitors drive intestinal inflammation via activation of toll-like receptor 4. J Exp Med. 2012 Dec 17;209(13):2395-408
47. Ford R. Gluten: Zero Global. YfoodX Ltd. Christchurch, New Zealand. 2012.

Celiac.com 06/23/2017 - Dr. Alessio Fasano from the University of Maryland's Celiac Research Center published a paper in Clinical and Developmental Immunology last month. It focused on a new drug developed by Dr. Fasano that has shown promising results in both animal and human trials. But is this the 'magic pill' that will cure celiac disease and gluten sensitivity? Let's take a look.

The new drug, formerly called AT1001 but now renamed Larazotide Acetate, is a zonulin inhibitor. For those who have never heard the word 'zonulin', you might think it's a term from a science fiction movie. But zonulin is the protein that causes the 'gates' or openings between the cells making up the lining of the small intestine to open and close. These openings are called tight junctions and when zonulin gets excessive, a leaky gut ensues.

Dr. Fasano has made great inroads to prove that a leaky gut is a problem that must be handled with gluten intolerance. The leaky gut perpetuates gluten's negative impact on other parts of the body. It can also initiate autoimmune disease.

One key point to keep in mind is that 'leaky gut' occurs because molecules can pass between cells when they shouldn't. In addition, molecules can pass through cells which they also shouldn't. Unfortunately this new drug only impacts the former, not the latter.

So, the drug Larazotide Acetate is a zonulin inhibitor. Now that we've reviewed what zonulin does as regards opening the gates, the purpose of inhibiting its action should make sense. How well does it work? In the recent human trials that were double-blind, randomized placebo-controlled (the best type of study, but I would expect no less from the stellar Dr. Fasano), a gluten exposure created a 70% increase in intestinal permeability (leaky gut) in 57% of the placebo group but only 28.6% of the patients receiving the drug (4 out of 14 patients) experienced such increased permeability.

Further, gastrointestinal symptoms were significantly more frequent among patients of the placebo group as compared to the group that received the Larazotide.

A pro-inflammatory substance known as interferon gamma was also evaluated. This is manufactured by the body when a specific foreign/toxic agent is recognized by the body's immune system. As expected, levels of interferon gamma increased in 4 out of 7 of the placebo patients (57%) but only 4 out of 14 larazotide patients (28.6%) saw any increase.

The good news is that this drug seems well tolerated and it does reduce the leaky gut response that gluten ingestion normally creates. Further, it also reduces the percentage, by about half, of the production of interferon gamma. These are all excellent results.

But, and it's unfortunately a very big 'but', we have a very long way to go before such a drug would be useful for your typical celiac or gluten sensitive patient. Will Dr. Fasano and his team be able to tweak this drug such that it functions at a higher level of efficacy? I certainly hope so, but let's analyze exactly what this drug does in its present state:

• The drug still resulted in almost 30% of the patients experiencing a 70% increase in permeability (leaky gut) – Not good.

A highly pro-inflammatory (this means that it creates degenerative disease) substance known as interferon gamma was also produced in nearly 30% of the drug-consuming patients tested – Not good.

Leakiness, or the passage of negative substances through cells is not affected by this drug – Not good.
Of course on the plus side, over 70% of those tested DID have a very good result with apparently no untoward side effects – Very good.

At what point is the efficacy high enough that you'd be willing to subject yourself to a possible reaction? Do realize that any gluten ingested increases your chance of disease, chief amongst them cancer and autoimmune disease. Is there a level of function of the drug that you would chance taking it? Is it 90%, 99%? Does any drug ever get that good?

Well, as a big fan of Dr. Fasano's, I would say that if anyone can do it, he and his team can. But at the same time, I cannot help but think of all the other drugs I have encountered. As 'wonderful' as they sometimes seem initially, they almost always fall from grace when some horrible side effect is realized.

Would I guinea pig my own health that I've fought so hard to regain? Would I recommend taking such a chance to my children just so that they could consume some white flour product? I don't think so.

How about you? What do you think? If the drug were available right now at its efficacy of 71%, would you take it and hope you weren't in the 29% for whom it didn't work? I'd love to hear your thoughts.

If you are wondering if you're gluten intolerant or know that you are but still aren't enjoying good health, consider calling us for a free health analysis: 408-733-0400. We are here to help! Our destination clinic sees patients from across the country and internationally so you do not need to live locally to receive assistance.

To your good health!

Reference:

• Alessio Fasano, Clinical and Developmental Immunology, Published online 2012 October 10. "Novel Therapeutic/Integrative Approaches for Celiac Disease and Dermatitis Herpetiformis."

Celiac.com 07/16/2013 - Gluten has a way of popping up in some very unexpected products.  Peers (whether online or otherwise) are sometimes our best resource for information regarding these oft-overlooked gluten-containing products, but sometimes speculation gets passed along the grapevine as fact. This has led to some very believable, but ultimately questionable rumors. Alcohol in particular has some of the most persistent rumors regarding gluten content. This is likely because the processes involved with alcohol production are confusing and widely misunderstood. With this article, I hope to address and clear up a few of the most persistent gluten-free alcohol misunderstandings that you've certainly heard before.

Misunderstanding #1: “Not all wine is gluten-free: some vintners age their wine in barrels that are sealed with a wheat paste. This paste contaminates the wine, making it dangerous for consumption by celiac disease sufferers.”

This is a big one. Wine is naturally gluten-free, but the fact that some vintners use wheat paste to seal their barrels has led many to cut wine out of their diets as a precautionary measure. It's a plausible idea, as some vintners do in fact use wheat paste to seal their barrel heads. However, there are a few key points here that you should consider before cutting wine out of your diet entirely:

1. Because the Tobacco Tax and Trade Bureau currently disallows gluten-free labeling of alcoholic beverages if the producer used “storage materials that contained gluten,” any wine that is labeled gluten-free was aged using a barrel alternative and carries no risk of contamination.
2. Wines that aren't labeled gluten-free might still be aged using barrel alternatives. Roughly speaking, the more expensive ($12+) Cabernet Sauvignons, Merlots, Zinfandels and red blends are more likely to be aged in oak barrels (and for a longer period of time).
3. The amount of wheat paste used to seal barrel heads is minimal. It is not the staves of the barrels that are sealed with a wheat flour paste, but the barrel heads.  Furthermore, most wineries thoroughly pressure wash all barrels with boiling hot water before they are used. The last thing vintners want is a contaminated product.

In order to lay this contamination issue to rest, Tricia Thompson tested a single winery's Cabernet Sauvignon and Merlot, which she was told by the winery were their two wines that spent the most time in wheat-sealed oak barrels. She tested each wine four times: twice with the Sandwich R5 ELISA test, and twice with the competitive R5 ELISA test. The competitive R5 ELISA is the current standard for detecting hydrolyzed (broken down) gluten, while the sandwich R5 ELISA is the current standard for detecting non-hydrolyzed gluten (1). Combined, the tests can reliably test for any possible form of gluten contamination.

Both extractions of both wines came back with the lowest possible results for both tests:

• Cabernet Sauvignon
  Sandwich R5 ELISA extraction 1: < 5 ppm gluten
  Sandwich R5 ELISA extraction 2: < 5 ppm gluten
  Competitive R5 ELISA extraction 1: < 10 ppm gluten
  Competitive R5 ELISA extraction 2: < 10 ppm gluten
• Merlot
  Sandwich R5 ELISA extraction 1: < 5 ppm gluten
  Sandwich R5 ELISA extraction 2: < 5 ppm gluten
  Competitive R5 ELISA extraction 1: < 10 ppm gluten
  Competitive R5 ELISA extraction 2: < 10 ppm gluten

Conclusion: Wine that is aged in oak barrels contains less gluten than we are currently capable of testing for, whether hydrolyzed or not.

At this point, a lot of people will begin to shake their heads: “If wine is gluten-free, then why do I get sick when I drink __________ wine?” The likely answer is that you are reacting to something else! Many winemakers use egg whites as a clarifying agent. The amount of egg used is far more substantial than any wheat paste that might have leaked into the wine, so if you know eggs are a problem, this is likely what you are reacting to.  

If you don't have a problem with eggs, you could also be reacting to sulfites. Many people have problems with them, and some winemakers use them as preservatives.
Sometimes, it's best to go out and get information directly from the winemaker. They can tell you more about their aging process, and shed light on what may or may not be making you sick.

Misunderstanding #2: “Distilled spirits that are derived from gluten-containing ingredients can be contaminated with gluten. Only distilled spirits made from non-gluten-containing ingredients, like potatoes, are safe for consumption by celiacs.”

This idea was likely propagated due to a misunderstanding of the distillation process. Here, I will refer to Megan Tichy, Ph.D's highly informative and clearly written description of the distillation process (2). It is a great read for those who are unclear on the process, and makes it very evident why all distilled spirits are gluten-free by definition.

To borrow Dr. Tichy's analogy, the distillation process is like boiling a kettle of water with sand at the bottom of it. Let's say you were to collect the water that boiled away as steam using a condensing tube. After boiling the entire kettle away, you would be left with a kettle with nothing but sand at the bottom of it, and a second container of pure distilled water.  There is no way the distilled water could contain any sand, as sand doesn't evaporate. In the same way, gluten doesn't evaporate, and gets left at the bottom of the 'kettle' during distillation. The likelihood of distilled alcohol being contaminated with gluten is about the same as the likelihood of you getting sand in your new cup of perfectly clean water: it would almost have to be intentional! Also keep in mind that many spirits are double, or even triple distilled. Gluten contamination over the course of a single distillation is already highly unlikely, but after consecutive distillations, it is virtually impossible.

To this, you might ask, “But what if they were to add other ingredients afterward? Those might contain gluten, right?” That's a perfectly valid concern, and yes, you should be concerned about any added ingredients. However, distilled spirits are almost always marketed based on their purity; this is why they go to all the trouble of double and triple distilling in the first place! Manufacturers of spirits want the most concentrated alcoholic product possible, so it is not exactly in their best interest (nor in common practice) to go adding more ingredients. Even so, you should always be mindful of ingredients lists, and cross check them against a reliable gluten-containing ingredients list (such as ours [3]).

Despite the fact that distilled spirits derived from grains are necessarily gluten-free, some people still seem to have problems with them. I don't have a ready explanation for this, as scientifically, it doesn't make sense. Celiac disease is triggered by gluten, and distilled alcohol contains no gluten. Here is a quick checklist to help rule out reasons why you may or may not react to such drinks:
[ ] Have you checked for cross contamination possibilities (glass, container, ice cubes, dish washing liquid, drying towel, etc.)?
[ ] Are you sure that you do not react to distilled alcoholic beverages that are not derived from grains (e.g. potato vodka)? (It could be a reaction to potent alcohol in general.)
[ ] Did you pour the drink yourself?
[ ] Are you sure you are not adding anything to the drink that could be cross contaminated or contain gluten?
[ ] Have you checked the ingredients list against a reliable gluten-containing ingredients list?
[ ] Have you considered any other allergies you have or might have?
[ ] Have you contacted the manufacturer for their official response regarding gluten content?

Oftentimes (especially soon after adopting GFD), the gut is still sensitive and cannot handle alcohol at high proof levels. If you had a bad experience with distilled spirits derived from grain early on in your GFD regimen, you might want to consider giving it another try after your villi have had a chance to heal. You really should not have a reaction once your gut is adjusted to the gluten-free diet. I know it is hard to trust a product derived from wheat, but distillation really, truly does remove all gluten, and it does so every single time.

Misunderstanding # 3: “'Low gluten' or 'gluten-removed' beers are unsafe, as gluten tests underestimate gluten content in beer. This is because the brewing process breaks the gluten molecules down into pieces that are too small for gluten tests to detect, but are still harmful.”

This is a point of fierce contention in the gluten-free community, and probably the most confusing argument to follow, as it all surrounds the validity of a variety of super scientific testing procedures. There isn't even a clear answer or 'winner' here, but I'm going to try and break all the information down for you, so you can make an informed decision about these products for yourself.

The main beef that people seem to have with gluten-removed beers is that they are derived from gluten-containing ingredients, and the gluten removal process is oftentimes undisclosed. This is an offshoot of the same distrust people feel toward distilled spirits, though perhaps a little more warranted given the fact that distillation is a very well documented and 100% reliable form of gluten removal, whereas as far as we know, these brewers are removing gluten using magic and fairy dust.

The reality is that these brewers (Widmer Brothers, Estrella Damm, Lammsbraeu, to name a few) are removing the gluten from their beer using one or the other, or perhaps a combination of two methods: filtration, and enzymes. Superfine filters can remove gluten particles from the beer, while added enzymes can target gluten particles, causing them to break down to a harmless state more quickly.

Whatever their methods, these beers need to have their gluten content verified using scientific testing procedures in order to be considered safe for consumption by celiacs. This is where things start to get murky.

As Tricia Thompson, MS, RD writes on her blog, Gluten-Free Dietitian, the current standard for testing gluten content in foods is a sandwich ELISA test (4). The R5 and omega-gliadin versions of the test are the most widely used, and both have been validated in collaborative trials.

While sandwich ELISA tests are reliable for detecting gluten in heated and non-heated food items, they are notoriously unreliable for detecting hydrolyzed gluten. Many see this as reason not to trust gluten-removed beers: the fermentation process hydrolyzes gluten in beer, so sandwich ELISA tests cannot accurately quantify their gluten content. If the test is unreliable, we are back where we started, with a once-gluten-containing product that has supposedly been rendered gluten-free by unexplained and unverifiable means; it's a hard pill to swallow!

However, the sandwich R5 ELISA's weaknesses are well documented and widely known. Most of these brewers are using an entirely different test that was specifically designed to detect partial gluten fragments (peptides) that may still be harmful to the gluten-sensitive. The competitive R5 ELISA is the standard test used to detect these peptides, and although it has not been validated yet, many published studies have found the competitive R5 ELISA to be a reliable indicator of hydrolyzed gluten (5) (6) (7).

This would all seem well and good since many of these beers test well under the proposed FDA limit of 20ppm gluten content with the competitive R5 ELISA. (As an aside, studies have shown 20 ppm to be an adequately conservative standard for most celiacs [8]). Unfortunately, the discussion doesn't end there. A recent Australian study tested a broad range of both beers brewed from alternate grains (sorghum, millet, etc.), and gluten-removed beers, and found that most gluten-removed beers contained significant levels of barley gluten (hordein) fragments, while beers brewed with alternative grains did not (9). 

Many have inferred two things from this study: 1) gluten-removed beers are unsafe, and 2) R5 ELISA testing under-reports, or is incapable of testing for the barley gluten, hordein. I would posit that these are both hasty conclusions to make, as the study begs the following questions:

How much gluten are we talking about?
It isn't entirely clear from the study what 'significant' levels are, as it quantifies hordein levels on a relative scale, but not in terms of ppm. Yes, it is clear from the study that truly gluten-free beers contain less hordein than gluten-removed beers. It would also seem that some hordein families are just as present in gluten-removed beers as in standard beers whose brewers make no claims as to their gluten content. But this does not mean that any of the beers are over the 20ppm standard. The study actually states that the gluten-removed beers were tested to under 10 ppm, but then indirectly implies that they were not actually under that threshold. This is not necessarily true though! One recent study found that around 50% of standard beers on the market actually test to under 20 ppm gluten content (10). In other words, the average gluten content of beer is lower than you might think. Just because gluten-removed beers may be closer to the average on the study's relative scale than might look safe, this does not mean they contain gluten at levels that would be harmful to the average celiac. Furthermore, the toxicity of hordein and hordein peptides for celiacs still hasn't been conclusively quantified (11).

Is R5 ELISA really that unreliable?
The study also makes some interesting claims about the limits of R5 ELISA testing procedures. Specifically, it claims that “The R5 antibody is unable to accurately detect and quantify barley gluten (hordeins) in beer.” This is a slightly misleading statement. It is true that the sandwich R5 ELISA can be inaccurate when detecting hordein levels, but it actually overestimates them, so long as they are not hydrolyzed. Furthermore, that is the sandwich ELISA; there is much evidence to suggest that the competitive R5 ELISA provides an accurate measurement of hordein peptides (6) (7) (12). Conversely, this study employed multiple reaction monitoring mass spectrometry, a testing procedure that has not been validated for gluten testing of foods or fermented alcoholic beverages. I would say that the competitive R5 ELISA has a more proven track record when it comes to testing for hydrolyzed gluten in beer.

What does it all mean then? Should I drink gluten-removed beer or not?
Well, that's up to you, of course. As I said before, this is a hotly debated and highly contentious issue in the gluten-free world right now, so I'm hesitant to take one side or the other. If you suffer from refractory sprue, or some other severe form of gluten intolerance, I would advise you to stay away, as the risk simply isn't worth it for you. For more mild sufferers of celiac disease or wheat sensitivity though, if you really miss the taste of beer and gluten-free beers just aren't doing it for you, there is no solid evidence to discredit the results of competitive R5 ELISA testing. Find a beer that is batch tested to under 20 ppm using this test (not sandwich R5 ELISA, though it wouldn't hurt if it was tested by both), try a few sips, and see if you react.

I've tried to provide all the key information so you can make an informed decision about these beers for yourself, but it never hurts to do your own research! Just know that there are a lot of biased and outdated sources out there; the more recent and scientific the study, the better!

References:
(1) Thompson, Tricia, MS, RD. “Wine Aged in Oak Barrels Sealed with Wheat Paste: Test Results for Gluten Contamination.” GlutenFreeDietitian.com, 10 Oct. 2012. Web. 20 Dec. 2012.
(2) Tichy, Megan, PhD. “Distilled Spirits (Grain Alcohols) and Vinegar: Are they Gluten-Free?” Celiac.com, 26 Aug. 2009. Web. 20 Dec. 2012.
(3) Adams, Scott. “Unsafe Gluten-Free Food List (Unsafe Ingredients).” Celiac.com, 27 Nov. 2007. Web. 20 Dec. 2012.
(4) Thompson, Tricia, MS, RD. “Standards for testing food for gluten: Issues that need addressing.” GlutenFreeDietitian.com, 6 Aug. 2012. Web. 20 Dec. 2012.
(5) Thompson, Tricia, MS, RD. “Beer: Why it is so hard to assess fermented and hydrolyzed products for gluten.” GlutenFreeDietitian.com, 24 Jul. 2012. Web. 20 Dec. 2012.
(6) Gessendorfer, Benedict, et al. “Preparation and characterization of enzymatically hydrolyzed prolamins from wheat, rye, and barley as references for the immunochemical quantitation of partially hydrolyzed gluten.” Analytical and Bioanalytical Chemistry 395.6 (Nov. 2009): 1721-1728. Web. 20 Dec. 2012.
(7) Haas-Lauterbach, S, et al.”Gluten fragment detection with a competitive ELISA.” Journal of AOAC International 95.2 (2012): 377-381. Web. 20 Dec. 2012.
(8) Thompson, Tricia, MS, RD. “How much gluten is 20 parts per million?” GlutenFreeDietitian.com, n.d. Web. 20 Dec. 2012.
(9) Colgrave, Michelle, et al. “What is in a Beer? Proteomic Characterization and Relative Quantification of Hordein (Gluten) in Beer.” Journal of Proteome Research 11.1 (2012): 386-396. Web. 20 Dec. 2012.
(10) Cane, Sue. “Gluten-free beer 2011. How is it made? How is its gluten content tested? And is it really safe for coeliacs?” FoodsMatter.com, 2011. Web. 20 Dec. 2012.
(11) Thompson, Tricia, MS, RD. “Barley enzymes in gluten-free products.” GlutenFreeDietitian.com, Jun. 2009 (updated 3 Feb. 2011). Web. 20 Dec. 2012.
(12) Guerdrum, Lindsay, Bamforth, Charles. “Levels of gliadin in commercial beers.” Food Chemistry  129.4 (2011): 1783-1784. Web. 20 Dec. 2012.