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Celiac.com 10/14/2023 - Celiac disease is a complex autoimmune condition that affects millions of people worldwide. For those with celiac disease, gluten, a protein found in wheat, barley, and rye, is the primary antagonist. When individuals with celiac disease consume gluten, their immune system mounts an attack on the lining of the small intestine, causing a range of digestive and systemic symptoms. The cornerstone of managing celiac disease has traditionally been a strict gluten-free diet. However, the landscape of celiac disease research is evolving. While gluten remains a central focus, emerging studies suggest that the triggers for celiac-related symptoms may extend beyond gluten-containing grains. Researchers and healthcare professionals are now exploring a broader spectrum of substances that may provoke adverse reactions in individuals with celiac disease. These lesser-known triggers and cross-reactive substances warrant closer examination to better understand their potential impact on those living with celiac disease. While gluten's central role in celiac disease is well-established, the emerging field of celiac research is shedding light on additional factors that might influence the disease's course and symptomatology. This expanded perspective acknowledges that, for some individuals, celiac-related symptoms may persist even in the absence of overt gluten exposure. Understanding these complexities requires exploring non-gluten triggers and cross-reactive substances that may affect individuals with celiac disease. Here we will to delve into these lesser-known sources of potential harm and offer insights into their significance within the celiac community. Non-Gluten Triggers Beyond gluten, there is increasing recognition that other components within grains or cross-reactive substances may trigger symptoms in certain individuals with celiac disease. For some, these non-gluten triggers are essential to consider when managing the condition and understanding why certain individuals continue to experience symptoms even on a strict gluten-free diet. One of the most debated non-gluten triggers in the celiac community is oats. Oats themselves are gluten-free, however, they are often processed in facilities that also handle wheat, barley, or rye. This cross-contamination can result in significant levels of gluten on the oats, which can lead to relapses and failure to recover in celiac individuals. To address this concern, certified gluten-free oats are available in many markets, providing a safe alternative for those who react to regular oats. Oats and Celiac Disease Oats, often hailed as a nutritious and versatile cereal grain, have become a topic of both excitement and contention within the celiac community. On one hand, oats are a naturally gluten-free grain, and their inclusion in the celiac diet can provide much-needed dietary diversity. On the other hand, concerns have arisen regarding the potential for oats to cause adverse reactions in individuals with celiac disease. As mentioned earlier, the primary issue with oats lies in their propensity for cross-contamination. Oats are frequently processed in facilities that also handle wheat, barley, or rye—the notorious gluten-containing grains. During processing, oats can come into contact with these gluten-containing grains, leading to contamination with gluten traces. For many years, this cross-contamination was a significant source of anxiety for individuals with celiac disease, prompting them to avoid oats altogether. However, research and the development of certified gluten-free oats have offered a glimmer of hope. These oats are produced under strict conditions to minimize the risk of cross-contamination, making them safe for most individuals with celiac disease. Additionally, General Mills has developed and patented technology that sorts oats and removes gluten grains to make the end product test below 20ppm. Despite this, oats remain a controversial topic within the celiac community. Some individuals with celiac disease can consume gluten-free oats without issue, enjoying the nutritional benefits they offer. For others, even certified gluten-free oats may trigger symptoms, raising questions about the role of non-gluten compounds in these reactions. One theory suggests that it's not the gluten in oats but rather the protein avenin that may cause some individuals with celiac disease to react. Avenin is a protein specific to oats, and while it shares some structural similarities with gluten proteins, it is distinct. Research indicates that most individuals with celiac disease can tolerate avenin, but a small percentage may react to it. The takeaway here is that oats can be a safe and nutritious addition to the celiac diet, provided they are gluten-free and well-tolerated. However, for those who continue to experience symptoms, even with gluten-free oats, it may be worth exploring other potential triggers and cross-reactivities in their diet. This underscores the importance of individualized care and monitoring for those with celiac disease, as responses to specific foods can vary widely among individuals. Cross-Reactivity with Other Grains While gluten-containing grains like wheat, barley, and rye are the primary culprits for individuals with celiac disease, it's essential to recognize that cross-reactivity can occur with other grains as well. Cross-reactivity refers to the phenomenon where the immune system mistakenly identifies a protein from another source as similar to gluten, triggering a response similar to what occurs with gluten ingestion. The Role of Other Proteins In addition to the well-known gluten proteins found in wheat (gliadin), barley (hordein), and rye (secalin), there are other proteins within grains that may contribute to celiac-like symptoms in some individuals. These lesser-known proteins have been the focus of recent research as scientists seek to unravel the complexities of celiac disease and its triggers. As mentioned earlier, one such protein is avenin, which is specific to oats. Avenin shares some structural similarities with gluten proteins, leading to questions about its potential to trigger reactions in individuals with celiac disease. Research suggests that most people with celiac disease can safely consume oats without adverse effects. However, a small subset may react to avenin, emphasizing the need for individualized dietary guidance. Beyond oats, other grains, such as sorghum and millet, have been investigated for their potential to cause cross-reactivity. While these grains are naturally gluten-free and are considered safe for most individuals with celiac disease, there have been anecdotal reports of adverse reactions. It's important to note that such reactions appear to be rare and not well-documented in scientific literature. Depending on where these grains are grown, and how they are processed, they too might be subject to cross-contamination with wheat, and unfortunately this concept has been understudied to date. In addition to specific grain proteins, other food components may play a role in celiac-like symptoms. Some individuals with celiac disease may be sensitive to fermentation byproducts or other compounds present in certain foods. For example, some alcoholic beverages, particularly those made from grains, may contain residual gluten or other substances that can trigger reactions. It's essential for individuals with celiac disease to exercise caution when consuming alcoholic beverages and to choose gluten-free options whenever possible. Fermentation and Hidden Sources Fermentation is a common process in food production, and it can introduce complexities for individuals with celiac disease. Some fermented foods, such as certain soy sauces and alcoholic beverages, may contain residual gluten or other compounds that can trigger reactions. It's crucial for those with celiac disease to be aware of these hidden sources of potential harm and exercise caution when choosing fermented products. Soy Sauce: Traditional soy sauce is typically brewed using wheat. However, gluten-free soy sauce alternatives are available, typically made with tamari or other wheat-free ingredients. These alternatives offer a safe option for individuals with celiac disease. Alcoholic Beverages: Some alcoholic beverages, particularly those made from grains like beer and certain spirits, may contain traces of gluten. It's advisable for individuals with celiac disease to choose gluten-free alcoholic options, such as gluten-free beer or spirits made from non-grain sources. Medications and Supplements Beyond dietary considerations, individuals with celiac disease must be vigilant when it comes to medications and supplements. Some medications and supplements may contain gluten as a binding agent or filler. While the overall gluten content in these products may be low, it can still pose a risk, especially for those with heightened sensitivity. It's essential for individuals with celiac disease to communicate their dietary restrictions with healthcare providers. Healthcare professionals can prescribe medications that are free from gluten or recommend suitable alternatives. Additionally, individuals should carefully read labels and seek out certified gluten-free supplements to minimize the risk of exposure. This site allow one to search prescription medications and see their inactive ingredients, which is the most common source of hidden gluten in medications. Understanding the potential for hidden sources of gluten in medications and supplements is an essential aspect of managing celiac disease. By working closely with healthcare providers and remaining vigilant about product labels, individuals can mitigate the risk associated with these often overlooked sources of gluten exposure. Cross-Reactivity Beyond Grains Celiac disease's complexity extends beyond gluten-containing grains. Cross-reactivity, where the immune system identifies proteins in non-grain foods as similar to gluten, warrants attention. Spices that Cross-react: Cross-reactivity between anti-gliadin antibodies and certain spice proteins indicates that patients with celiac disease or wheat allergies may also have an intolerance to many spices, even if they are gluten-free. Some spices can also be a source of cross-contamination, as wheat flour may be used as an anti-caking agent. Food Additives: A recent study indicates that Silicon Dioxide (Food additive E551) May Trigger Intestinal Damage and Inflammation in People with Celiac Disease or Gluten Sensitivity. Other studies have shown that meat glue (Microbial transglutaminase) can trigger celiac symptoms in some celiacs, which is used widely in lunch meats and other products. Examining Cross-Reactivity with Non-Grain Foods: Some individuals with celiac disease may experience adverse reactions to foods not typically associated with gluten. These reactions can stem from proteins in foods like dairy, coffee, or chocolate that bear structural resemblance to gluten. While cross-reactivity is a concern, it varies among individuals, highlighting the importance of personalized dietary management. Highlighting Potential Triggers in a Varied Diet: A diverse diet can inadvertently introduce unfamiliar triggers. Celiac patients should maintain a symptom diary to identify potential culprits. Consultation with a dietitian is invaluable for crafting a balanced and safe eating plan. Diagnosis and Testing for Cross-Reactivity Diagnosing cross-reactivity requires careful assessment and monitoring. Methods for Diagnosing Cross-Reactivity: Diagnosing cross-reactivity relies on a process of exclusion. Potential triggers are eliminated from the diet, and symptoms are closely observed. Medical professionals may recommend additional tests like food allergy testing or intestinal biopsies to detect inflammation or damage resulting from specific dietary components. The Importance of Comprehensive Testing for Celiac Patients: It's vital for individuals with celiac disease experiencing persistent symptoms or suspected cross-reactivity to collaborate closely with healthcare providers. Gastroenterologists and dietitians can facilitate thorough testing, including serological tests for celiac disease to verify dietary compliance, and assessments for potential allergic reactions to other grains or proteins. Managing Lesser-Known Triggers Comprehensive management of celiac disease extends beyond gluten avoidance. Practical Tips for Individuals with Celiac Disease: To navigate the intricacies of non-gluten triggers, individuals should prioritize dietary awareness. Reading labels diligently, inquiring about ingredients when dining out, and opting for certified gluten-free products are essential practices. It's also beneficial to maintain open communication with healthcare providers and maintain a symptom diary. Strategies for Minimizing Exposure to Lesser-Known Triggers: Individuals can minimize exposure to potential triggers by choosing gluten-free alternatives for favorite foods. Additionally, they should exercise vigilance regarding cross-contamination in shared kitchens or dining establishments, select gluten-free alcoholic beverages, and verify the gluten-free status of spirits. Conclusion Understanding celiac disease's intricacies, including non-gluten triggers and cross-reactivities, is paramount for individuals' well-being and ongoing research in the field. In the ever-evolving landscape of celiac disease research and understanding, it's clear that gluten is just one piece of the puzzle. While gluten remains a central concern for individuals with celiac disease, exploring non-gluten triggers and cross-reactive substances is vital to comprehensively manage this complex condition. By acknowledging the potential impact of oats, cross-reactivity with other grains, the role of lesser-known proteins, fermentation, hidden sources, and medication considerations, individuals with celiac disease can better navigate the challenges they may encounter. Additionally, close collaboration with healthcare providers and dietitians is crucial to developing individualized strategies for managing celiac disease effectively. As research continues to shed light on these lesser-known triggers, the celiac community can look forward to improved diagnostic methods and a deeper understanding of the factors that influence celiac-related symptoms. This ongoing exploration underscores the importance of ongoing awareness, education, and support for individuals living with celiac disease.
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Celiac.com 08/24/2019 - Are you 100% gluten-free, yet you still suffer from symptoms related to gluten? If so, it could be that you're experiencing “Cross-Reactivity,” or are sensitive to foods that do not contain gluten but your body reacts to them as if they do. Cross-Reactivity is the ability of an antibody to react with similar antigenic sites on different proteins. There are a number of naturally gluten-free foods such as cheese, chocolate and coffee, which contain proteins so similar to gluten that your body may confuse with gluten. When you eat these foods, your body and immune system react as if you just ate a bowl of whole-wheat pasta. It's estimated that at least half of those who are gluten intolerant are also sensitive to dairy (cheese, yogurt, milk and butter) due to its cross-reactivity with gluten. The protein in coffee is the most common cross-reactor to gluten. Because it is the protein in the coffee that is the trigger, switching to decaf coffee does not solve the problem. In fact, decaf coffee is heavily processed so you don't want to drink it in any case. Below is a list of common foods that may trigger a reaction in some celiacs: Amaranth Buckwheat Chocolate Coffee Corn Dairy, i.e. milk and cheese (alpha-casein, beta-casein, casomorphin, butyrophilin, whey protein) Egg Hemp Millet Oats Potato Rice Sesame Sorghum Soy Tapioca Teff Yeast If you are off the gluten and are still having health issues, try eliminating the above foods for at least two months and see if your symptoms improve. Also, it's important to make sure you've done the Four R's to heal the gut. Then, after two months you may reintroduce the above foods one at a time to determine which ones are causing reactions, if any at all. An easier way to find out exactly what foods you are reacting to is to run an IgG Panel (food intolerance). This way you don't have to play the guessing game. The IgG Panel we use if with Great Plain Labs and covers 92 foods along with yeast, candida levels and coffee. If you determine that there are foods that are cross-reactive for you, the treatment is to permanently remove these foods from your diet in addition to gluten. Remember, even though the cross-reactive foods do not actually contain gluten, your body may think they do, and they may also cause some level of inflammation and damage to your body. Gluten-free is a good baseline in starting to heal your gut, however in most cases it only part of the whole protocol. Once the body is "confused" it's important to look at healing the gut and calming the inflammation down. Inflammation is the bottom line and causes 80% of disease. Our focus here is finding its cause and addressing it.
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Celiac.com 02/15/2019 - Answer this question honestly for yourself. Not for me, or for anyone else, answer this question honestly for yourself. On a scale from 1 to 10, if 10 is the amount of energy you should have in life, and 5 is half as much… now, hold on a minute, one more thing, take your will power out of the equation… what’s your body energy? If you weren’t pushing yourself, motivating yourself to continue on, what is the level of energy your body is operating on? On a 1-10 scale? Most of us have a number we come up with right away as the first part of the question is being asked: “Oh, I’m an eight or a nine”. But when I ask patients to take their will power out of the equation, many will have a look come across their face, almost like a balloon being deflated a little, and they’ll say “three” or “five”. Rarely do I have someone who answers eight or above. Where is this fatigue coming from? Many clinicians will tell you one of the most common symptoms of food allergies and food sensitivities is fatigue. Although the majority of individuals with gluten sensitivity and/or celiac disease experience substantial improvement within the first few weeks of gluten withdrawal, between 7% and 30% continue to have symptoms or clinical manifestations suggestive of celiac disease despite being on a gluten-free diet(1). That’s called non-responsive celiac disease--the body is not responding the way it should. Why is that? And why is it that so many of us do not experience the amount of energy we should feel given that we’re being so careful to avoid exposure to gluten, a food that is toxic to us? We’ll look, in this article, at a common, hidden source of this lack of vitality and lack of response to a gluten-free diet. Non-responsive celiac disease (NRCD) has been defined as: referral to a clinician specializing in celiac disease for the evaluation of a lack of response to a gluten-free diet, failure of clinical symptoms or laboratory abnormalities typical of celiac disease to improve within six months of gluten withdrawal, recurrence of symptoms and/or laboratory abnormalities typical of CD while on a gluten-free diet. In one study, 12 identified causes of NRCD, the most common cause was (inadvertent) gluten exposure, accounting for 36% of patients(2). OK, that’s understandable. But what about the other 64% who did not have an inadvertent exposure to wheat or similar grains? What is the cause of their NRCD? An all-too-common contributor to NRCD is sensitivity to other foods commonly consumed on a gluten-free diet causing a very similar inflammatory cascade in the intestines. Another contributor is cross-reactivity of antibodies against gluten with exposure to other foods. On a gluten-free diet, we may substitute other grains in much larger amounts than we may have eaten when we were on a gluten-containing diet. In some cases, this may initiate an immune response very similar to that caused by eating gluten. Cross-reactivity is the ability of an antibody to bind to similar-looking parts on different proteins called epitopes. This phenomenon is also known as molecular mimicry. In such a case the immune system confuses one food for another. Therefore, certain foods appear, to the immune system, sufficiently similar to a reactive food to initiate an immune response. Patients with gluten sensitivity and celiac disease may be sensitized to a broad range of dietary proteins from different foods due to cross-reactivity. Below is a drawing of what happens when the gliadin protein molecule from wheat (labeled #1) fits into the ‘docking station’ of a wheat antibody. It fits into all three locks of the docking station. This is termed a reactive antibody. And in gluten sensitive individuals, the immune system is activated to make more antibodies to fight this invader. As we all know, that is not a problem unless we eat the offending food so often that it overwhelms the body and begins causing a great deal of damage to the intestines and other tissues (pancakes for breakfast, sandwich for lunch, pasta for dinner, toast for breakfast, sandwich for lunch, croutons on the salad at a dinner, and maybe a cookie or piece of cake,..). Next we see how some foods (such as casein from dairy) can bind to a gliadin antibody. It fits into two of the three ‘docking stations’ and that is enough to trigger an immune response as if this person was eating gluten. This will still trigger an immune response. That food is called a ‘cross-reactive’ food. In the third drawing we see how other foods (such as rice) may bump into a gliadin antibody, but it only fits into one docking station, or no docking station and thus will not bind to it. This is similar to putting a round peg in a square hole - can’t do it. It is ignored by the gliadin antibody. With wheat the estimated prevalence of a cross-reactivity with rye and barley is one out of five (20%) (3). Cross reaction with dairy in different studies varies from 50 to 91%(4,5). Up to 82% of patients with celiac disease have antibodies to other foods including rice flour, milk, beef, sheep and egg(6). Other studies have identified cross-reactivity with chocolate(7), sesame(8,9,10,11,12), hemp(13), rye(14), kamut(15,16), buckwheat (17,18,19,20,21,22,23,24,25), sorghum(26,27,28,29,30), millet(31,32,33,34), spelt(35,36,37,38), amaranth(39,40,41), quinoa(42,43,44), yeast(45,46,47,48,49), tapiocal(50,51,52,53), oats(54,55,56,57,58,59), coffee(60,61,62,63,64), corn(65,66,67), ricel(68,69,70,71,72), potato(73,74,75). The response to some of these food allergens parallels the response to the gluten protein in wheat with increased IgA antibodies and might be relevant to the ongoing immune response of gluten sensitivity and celiac disease without eating gluten(76). Perhaps this is why as many as 40% of children on a well-managed gluten-free diet for at least 1 year still have elevated antibodies to gluten(77). From the diagnostic and therapeutic point of view, it makes sense to define allergen clusters (cross-reactivity)(78). Determination of serum IgA and IgG antibody activities to dietary proteins appears to be a valuable adjunct in the diagnosis and follow-up of celiac disease, both in children and adults. Increased IgA activities to other dietary antigens are likewise relatively characteristic of untreated celiac disease; monitoring of such antibodies may be particularly helpful in evaluating the response of patients on a gluten free diet(79). Foods that may create cross-reactivity with gluten include cow’s milk, casein, casomorphin, American cheese, chocolate, rye, barley, kamut, spelt, yeast, oats, and coffee. Common foods often included on a gluten-free diet that one may be sensitive to that could cause continued inflammation include sesame, rice, corn, potato, hemp, buckwheat, sorghum, millet, amarath, quinoa, and tapioca. This array of 24 different foods (some are possible sensitivities while others are possible cross-reactive foods) is available from CyrexLabs.com. Ask your Health Care Practitioner to look into this array. You might want to consider that, when a gluten-free diet is not producing the results that you had hoped for, the cause may be another common food. If you are working so hard to be in control of the quality and the selection of the foods you eat, this concept of cross-reactivity may be a missing-link that will help you get closer to feeling great and answering that initial question “On a 1-10...” with a passing grade of 7 or higher. Dr. Thomas O’Bryan is a nationally recognized speaker and workshop leader specializing in Gluten Sensitivity and Celiac Disease. He is the Sherlock Holmes for chronic disease and metabolic disorders. He is a clinician par excellence in treating chronic disease and metabolic disorders from a Functional Medicine Perspective. He holds teaching Faculty positions with the Institute for Functional Medicine and The National University of Life Sciences. Dr. O’Bryan is always one of the most respected, highly-appreciated Speakers. Dr. O’Bryan’s passion is in teaching the many manifestations of Gluten Sensitivity and Celiac Disease as they occur inside and outside of the intestines. Dr. O’Bryan welcomes your questions about gluten sensitivity and/or functional medicine. Please send your questions and requests by email to www.theDr.com. References: 1. Green P, Cellier C, Celiac Disease NEJM 357;17 Oct 25, 2007 2. Leffler DA, Dennis M, Hyett B, Kelly E, Schuppan D, Kelly CP., Etiologies and predictors of diagnosis in nonresponsive celiac disease, Clin Gastroenterol Hepatol. 2007 Apr;5(4):445-50 3. Sicherer SH., Clinical implications of cross-reactive food allergens, J Allergy Clin Immunol. 2001 Dec;108(6):881-90 4. Kristjánsson G, Venge P, Hällgren R., Mucosal reactivity to cow’s milk protein in coeliac disease, Clin Exp Immunol. 2007 Mar;147(3):449-55 5. Bürgin-Wolff A, Hernandez R, Just M, Signer E., Immunofluorescent antibodies against gliadin: a screening test for coeliac disease, Helv Paediatr Acta. 1976 Dec;31(4-5):375-80 6. 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