Celiac Disease Symptoms and Gluten-Free Diet Information

Gluten Free Low Glycemic Cookbook

Fun With Gluten-Free, Low-Glycemic Food Cookbook is an ebook cookbook by Debbie Johnson, former owner and executive chef of The Golden Chalice Restaurant & Gallery, a 100% gluten-free, sugar-free, low-glycemic, organic, allergy-friendly establishment. This is the first Cook-Book of its kind! Every Recipe is Completely Gluten-Free, Sugar-Free (except fruit), Digestion-Friendly, Allergy-Friendly and Low Glycemic with Meat, Poultry, Fish meals and Tree-Nut-Free, Dairy-Free, Vegan and Vegetarian Options for most recipes. The recipes in this ebook have been helpful for people with everything from celiac disease and diabetes to Ibs (irritable bowel syndrome). Also, every recipe in this book contains healing food of some type. This is according to the many books written by doctors who are experts in the field of nutrition. Read more here...

Gluten Free Low Glycemic Cookbook Summary


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Contents: 95 Page Ebook
Author: Debbie Johnson
Official Website: glutenfree-lowglycemic-diet.com
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My Gluten Free Low Glycemic Cookbook Review

Highly Recommended

All of the information that the author discovered has been compiled into a downloadable book so that purchasers of Gluten Free Low Glycemic Cookbook can begin putting the methods it teaches to use as soon as possible.

When compared to other ebooks and paper publications I have read, I consider this to be the bible for this topic. Get this and you will never regret the decision.

The Specificity of tTG Is Linked to Gluten Toxicity

A striking feature of gluten modification by tTG is that only particular glutamine residues are modified. In the HLA-DQ8-restricted gliadin peptide, for example, four glutamine residues are present, but tTG only modifies those at the p1 and p9 positions, but not those at the p5 and p8 positions (van de Wal et al., 1998b). Replacement of these latter glutamine residues by glutamic acid, however, completely abrogates the T cell stimulatory properties of this peptide (van de Wal et al., 1998b). Similarly, in other gluten peptides only those glutamine residues are modified that are important for the generation of potent T cell stimulatory peptides (Arentz-Hansen et al., 2000 Vader et al., 2002a,b). The selective modification of gluten peptides by tTG is thus tightly linked to gluten toxicity. An analysis of the modification of large series of gluten peptides by tTG indicated that the spacing between glutamine and proline residues in gluten pep-tides has a major influence on the...

The HLA Gene Dose Effect Is Linked to the Level of Gluten Presentation

Two types of HLA-DQ2 molecules are known. While the DQ2 molecule associated with the DR3 haplotype predisposes to CD, that associated with DR7 does not (Sollid et al., 1989). Yet, both molecules have almost identical peptide-binding properties and would thus be expected to present gluten pep-tides to T cells (van de Wal et al., 1997). An extensive analysis of the peptide-binding properties of DR7DQ2, however, revealed that this molecule can only bind and present a small subset of gluten peptides (Vader et al., 2003b). This is due to a subtle difference in the binding groove of DR7DQ2 that prohibits the presence of a proline at position 3 in the bound peptides (Table 11.1 van de Wal et al., 1997). In contrast, DR3DQ2 does tolerate a proline at position 3, and since this residue is invariably found in T cell stimulatory gluten pep-tides, DR3DQ2 can present a far larger repertoire of such peptides compared to DR7DQ2 (Table 11.1 Vader et al., 2003b). This result implies the existence of a...

Hard Grain Wheat Gluten

Commercial producers make pasta from hard-grain wheat. In the absence of egg the protein network is formed by proteins in the wheat and, more precisely, in its gluten. If one takes the mass obtained after kneading flour and water for a long time and then rinses it under a stream of running water, the elastic matter that remains is composed of gluten proteins. Because this substance is more abundant in hard wheats than soft ones, laboratories such as the one in Montpellier are interested in the composition and genetic variability of hard-wheat proteins and in methods of making of pasta that favor the formation of a protein network. The quality of a good commercial pasta is judged by its yellow-amber color and its culinary properties, which is to say the likelihood that it will not stick after cooking (or even after being slightly overcooked). Plant geneticists therefore have looked to develop hard wheats with firm and elastic gluten. The inra biochemists showed that this latter...

Diagnosis of celiac disease

There is a significant role for serological tests in the diagnosis and management of celiac disease. Antigliadin antibodies (AGA) measured by enzyme-linked immunosorbent assays are a sensitive although nonspecific test for the presence of celiac disease. False-positive gliadin antibodies have been reported in other conditions including small bowel bacterial overgrowth as well as in healthy individuals. This is particularly true for IgG AGA, which has a high false-positive rate. IgA AGA is more specific, but its sensitivity ( 80 ) is less, in part due to the fact that IgA deficiency is increased in celiacs. The use of antigliadin antibodies in the detection of celiac disease has been recently questioned because of their lower specificity. However, they can play a role in assessing young children in whom tTG assays are less sensitive 45 and in following some celiacs on a gluten-free diet when the tTG levels are slow to decline. Serum antireticulin antibodies (ARA) should no longer be...

Complications of celiac disease

Malignancy is the most feared complication of celiac disease, but more concerning than the risk of malignancy are other, more common complications of celiac disease that can develop when celiac disease is not recognized and or treated. These include osteopenic bone disease, growth retardation in children, iron deficiency and other nutritional deficiencies. There are also issues related to fertility including increased rates of infertility, spontaneous abortions and intrauterine growth retardation that are associated with untreated celiac disease 21-24 . There is some suggestion that untreated celiac disease may be complicated by developing other autoimmune diseases at a higher rate than expected, but this may only be true in children, and even then, not all studies support this observation. Complications of the malabsorption associated with celiac disease include metabolic bone disease, anemia and other manifestations of nutritional deficiencies. Celiac patients may also develop...

Benefit of a Gluten Free Diet

Although general clinical experience and the literature suggest that most adult celiacs are not highly compliant with a gluten-free diet, most patients are symptom free in spite of continued gluten ingestion. As discussed above there is some evidence that the incidence of malignancy is reduced in celiac patients and those with DH who adhere to a gluten-free diet. Other benefits of a gluten-free diet include improvement of body size and composition, iron deficiency 52 and osteopenia. There is also the suggestion from some studies that a gluten-free diet may delay or prevent the development of other autoimmune disorders, although this is not supported by other reports 78 . The question of how much gluten is safe remains unanswered. In the absence of data to support specific recommendations, patients should be encouraged to stay free of dietary gluten wherever possible in order to induce and maintain remission and potentially prevent complications of the disease.

Prevention of celiac disease

Given the growing rise in prevalence of celiac disease, there is interest in trying to prevent the development of celiac disease. There are studies that suggest breast-feeding and delayed introduction of gluten into the diet may reduce the risk of developing celiac disease 82, 83 . However, while these observations make sense, there are other reports that suggest early introduction of gluten in a defined period of time in infancy may also reduce the risk 84, 85 . There is also interest in whether dietary changes such as increased consumption of strains of wheat that contain greater amounts of potentially immunogenic peptides could play a role in the apparent increase in celiac disease 86 . Further studies are needed to answer these questions.

Gluten and caseinfree diet Opiod excess theory

Much research has been undertaken and is still ongoing, into the biological causes of autism and related disorders. One theory that has much anecdotal evidence (my own boys being an amazing testimony ) to suggest its efficacy, is that gluten (the protein found in certain grains) and casein (the protein found in dairy produce) cannot be broken down properly by people on the autistic spectrum. This results in peptides being produced and these leak into the bloodstream and cause innumerable problems. Gluten is broken down into gluteomorphine and casein is broken down into caseomorphine and as you can probably surmise by their names, these peptides have an opiate effect. By removing the offending foods, the production of these peptides is stopped and therefore so does their opiate effect. have said, this is only a theory. I can say that it is a theory that is tried and proven to be beneficial to autistic children throughout the world and Luke wrote his first book - A User Guide to the GF...

Screening for celiac disease

Because of concerns relating to the complications of not recognizing celiac disease and leaving it untreated, screening for celiac disease has been advocated. The disease itself does meet established criteria for screening, but there are issues related to resources and also ethical considerations that weigh against widespread screening programs for detecting celiac disease. Screening has been advocated in some settings including relatives of those with celiac disease and in type I diabetics, but none of the recommendations for screening is without controversy 79-97 .

Mortality associated with celiac disease

Various studies suggest that there is a small increase in mortality in subjects with celiac disease compared to the general population, which returns to baseline within a few years. In two recent studies the standardized mortality ratio was 2.0 53, 54 . In another recent study the hazard ratio for all mortality was 1.31, and this fell to 1.17 the 1st year after treatment 55 . In an earlier study, five-year survival was the same for celiac patients as for the general population 56 . Corrao et al. performed a large study of Italian celiacs, which showed that there was a small increase in death rate returns to baseline in the first few years after diagnosis 53 . In this study increased mortality was observed in subjects with malabsorptive presentations if the diagnosis was delayed and in those poorly compliant with diet. The main cause of excess death in this study, as in others, was lymphoma

T Cell Recognition of Gluten Peptides

It is well established that CD is almost exclusively associated with HLA-DQ2 and -DQ8. While approximately 95 of the patients are HLA-DQ2-positive, the remainder are usually HLA-DQ8-positive (Marsh, 1992). Moreover, Lundin et al. (1993) found that HLA-DQ2- and HLA-DQ8-restricted, gluten-specific T cells are present in the small intestine of CD patients. These findings indicated that these DQ molecules have unique peptide-binding properties that set them apart from other HLA class II molecules. Several studies have investigated the peptide-binding properties of HLA-DQ2 (Table 11.1) (Kwok et al., 1996 van de Wal et al., 1996 Vartdal et al, 1996 Godkin et al, 1997). HLA-DQ2 was found to selectively bind peptides with large hydrophobic residues at positions p1 and p9, a negatively charged amino acid at positions p4 and or p7, and a proline residue or a negatively charged amino acid at position p6 (Table 11.1). Similarly, HLA-DQ8 was found to have a preference for anchor residues with a...

Chemists look to improve bread dough by investigating the protein bonds that form its glutenous network

The behavior of wheat flour can be understood by analyzing the properties of its two main components starch granules, which swell up in the presence of water, and proteins, which form a glutenous network as dough is kneaded. How do the forces among proteins contribute to the mechanical properties of the dough It has long been known that bonds between the sulfur atoms found in wheat proteins play a role in structuring gluten. Other forces have been discovered as well. Gluten is a viscoelastic network of proteins that becomes elongated by pulling and then partially reverts to its initial form when the tension is relaxed. The quality of bread depends on the quality of its gluten. Indeed, gluten is what makes breadmaking possible Yeast produces carbon dioxide bubbles, with the result that the volume of the dough increases, and the protein network of the gluten preserves the dough's spherical shape by retaining these gas bubbles. It therefore becomes necessary to understand the...

The Gluten Free Diet

The management of confirmed celiac disease is a life-long diet that is devoid of gluten. While this seems like a simple treatment it is often difficult for patients to comply with this dietary restriction. Factors that contribute to non-compliance include the lack of readily available gluten-free foods, particularly when eating out of the home, the less acceptable taste of gluten-free products and the difficulties associated with preparing dishes with gluten-free ingredients 72 . Inadvertent ingestion of gluten may occur as a result of trace amounts of gluten in a wide variety of food stuffs and medications, contamination of gluten-free products with gluten during processing and misinformation about food contents on the part of manufacturers, restaurant staff and even well-meaning friends and relatives. The diet poses particular difficulties for children, teenagers and their parents. Newly diagnosed celiacs should be encouraged to join local chapters of the various national celiac...

Spectrum of clinical presentations and associated conditions

The classical presentation of celiac disease includes diarrhea, failure to thrive or weight loss, abdominal distention, flatulence and fatigue. However, during the past two decades there has been an increasing awareness that there are many less dramatic or classical presentations of celiac disease including iron-deficiency anemia, folate deficiency, osteopenic bone disease, as well as relatively non-specific gastrointestinal (GI) symptoms (Table 6.2). These so-called atypical forms of celiac disease are now more common than classical celiac Table 6.2 Presentations of Celiac Disease Classical celiac disease of childhood Later onset GI symptoms Often mistaken for IBS Can be non-specific Extraintestinal presentations Dermatitis herpetiformis Iron deficiency Folate deficiency Osteopenic bone disease Chronic fatigue Obstetrical complications Asymptomatic celiac disease Often in relatives Latent celiac disease disease 4 . Studies as well as anecdotal experience indicate that many of these...

Dermatitis Herpetiformis

Dermatitis herpetiformis (DH) is a condition characterized by pruritic papulovesicular skin lesions in which granular or linear IgA deposits are found at the dermal-epidermal junction 10 . The majority of patients with DH have the characteristic findings of celiac disease in small bowel biopsy specimens, although relatively few have GI symptoms. DH patients have similar HLA profiles to celiac patients and develop similar antibody elevations to gliadin and tissue transglutaminase (tTG). They are also at increased risk of malignancies as discussed later. Institution of a gluten-free diet will reverse both the skin and intestinal lesions, while standard therapies for DH such as dapsone improve only skin disease. It is not clear why only a small subset of celiacs has DH, while virtually all DH patients have the intestinal pathology of celiac disease.

Other Diagnostic Tests

While individuals presenting with severe and classical celiac disease may have steatorrhea and evidence of malabsorption including decreased serum levels of cholesterol, carotene, calcium, magnesium, phosphorus, potassium and albumin, increased levels of alkaline phosphatase and a prolonged prothrombin time, many patients with celiac disease do not have overt malabsorption. More common laboratory manifestations are parameters of iron deficiency and sometimes folate deficiency. Vitamin B12 deficiency can occur in celiac disease, but is relatively rare. The D-xylose test and barium studies have little role in the current assessment of patients with celiac disease. Endoscopic findings include scalloping or the absence of duodenal folds, but these are both insensitive and not entirely specific markers for celiac disease 51 . Videocapsule imaging and enteroscopy can play a role in addition to standard esophagogastroduodenoscopy in some cases of celiac disease 49 .

Strategies for confirming a diagnosis

Increasing numbers of patients are labeled as having celiac disease based on serological testing or even clinical presentation alone. A beneficial response to a gluten-free diet does not indicate celiac disease as it is not unusual for patients with irritable bowel syndrome and other conditions to benefit from such a diet. Individuals who have been diagnosed as having celiac disease without initial biopsy specimens obtained while on a gluten-containing diet should undergo additional testing including HLA testing and gluten challenge to confirm the diagnosis (Table 6.5). The optimum length of the gluten challenge has not been defined, but the recent literature suggests that serological and histological changes can be found as early as after one to two weeks of a diet containing at least 10 g of gluten per day (equivalent to four slices of bread). Sensitivity varies, however, and some patients quickly become ill on smaller amounts of gluten, while others, particularly those who have...

Small Bowel Adenocarcinoma

Small bowel (SB) cancers also occur with increased frequency in patients with celiac disease. The true risk of SB adenocarcinoma is unknown, but the older literature suggested relative risks ranging to over 82. A more recently published study with a strong study design suggests that the risk of SB adenocarcinoma is increased approximately ten-fold in celiac disease 64 . Other recent studies report the risk of small bowel adenocarcinoma ranging from no increased risk 65 to a standardized mortality rate of 34 69 . It is generally thought that there is no evidence for a polyp-cancer sequence in celiac disease-associated small bowel adenocarcinoma, but one report of seven cases of SB neoplasia showed three adenomas and four adenocarcinomas, with one being adjacent to a jejunal tubulovillous adenoma 70 .

Prevention of and Screening for Malignancy

Although there are no prospective randomized trials that address the hypothesis that a gluten-free diet protects against the development of malignancy, the available literature does support this hypothesis. As reviewed in recent articles by Loftus and Loftus 71 and by Catassi et al. 62 , studies published over several decades and from various countries indicate the risk of malignancies is reduced or decreases to baseline after being on a gluten-free diet. There are inherent methodological flaws with many of the studies including reliance on self-reporting of whether subjects were gluten free and to what degree they were able to comply with the diet over time. In spite of the limitations of the studies, the findings that a gluten free-diet reduces cancer risks are consistent with the observation that chronic inflammation is generally associated with an increased risk of malignancy and thus a reduction in immune stimulation on a gluten-free diet should be of benefit. As in any condition...

Other Nutritional Considerations

Newly diagnosed patients with malabsorptive symptoms should adhere to a lactose-free diet for the first few weeks on a gluten-free diet. This time period will allow for healing of the intestinal epithelium and regeneration of intestinal lactase unless the patient has constitutive lactose intolerance in which case the patient should be maintained on a lactose-free diet. Adequate calcium intake must be insured, especially in this latter group of patients, since celiac patients are at risk of osteopenic bone disease 77 . Until their nutritional status is restored,

Nonspecific gastrointestinal symptoms and other nonmalabsorptive presentations

Patients with celiac disease can present with altered bowel habits, bloating, dyspepsia and abdominal discomfort 5 . Some studies suggest a subset of patients diagnosed as having irritable bowel syndrome (IBS) may have celiac disease 6, 7 . The mean prevalence of celiac disease was 3.4 in published series of IBS patients, and celiac disease is seven times more common in IBS patients than in age-matched controls. A recent decision analysis study suggests that there is an acceptable cost of testing for celiac disease in diarrhea predominant IBS patients when the prevalence of celiac disease is greater than 1 8 , and another study suggests celiac screening is more worthwhile than searching for infections, malignancies and inflammatory bowel disease in IBS subjects with diarrhea 9 .


Until the advent of widespread serological testing the highest reported prevalence of celiac disease in the world was in western Ireland where 1 in 300 individuals had celiac disease with prevalence as low as 1 2,000 in other parts of Europe. It was estimated that 1 in 2,000 Canadians had celiac disease, while one study conducted in Olmstead County, Minnesota, reported a prevalence of 21.8 per 100,000 2 . It is still not clear why the reported frequency of celiac disease was so much less in the USA than in other parts of the world inhabited by individuals of similar ethnic origin. The use of serological methods to screen for celiac disease indicates that celiac disease is much more common than previously thought, with prevalence as high as 1 50 to 1 300 in the western world. A recent prevalence study conducted in the United States by Fasano and colleagues indicated a prevalence of 1 133 in asymptomatic subjects, but higher in symptomatic subjects or those with disorders associated...


Inappropriate T-cell responses to ingested gluten in genetically predisposed individuals results in the intestinal injury that characterizes celiac disease 30-31 . The discovery that tissue tTG is a target of the immune response in celiac disease has enhanced the understanding of the patho-genesis of the disease and led to the development of new diagnostic tests 32 . Prolamins (gliadin in wheat, secalin in rye and hordein in barley, collectively referred to as gluten) have been identified as the component of those grains capable of inducing damage in celiacs 3334 . Over 50 peptides have been shown to stimulate T cells in celiac subjects, although a given patient may react to only a few of these peptides. Most recent studies suggest that avenin in oats does not induce immunoreactivity 35 , although there are reports to suggest that some T cells may react to oat-derived peptides 36 . There is also some evidence that in celiac subjects regulation of the intestinal tight junctions is...


The diagnosis of celiac disease still requires a characteristic appearance on histological examination of mucosal biopsy specimens obtained from the small intestine. These findings include varying degrees of Strategy to Diagnose Patients on a Gluten-free Diet without a Confirmed Diagnosis of Celiac Disease Patients started on gluten-free diet (GFD) without confirmatory histology Patients with an equivocal diagnosis or equivocal response to GFD Those who are HLA DQ2 and or DQ8 positive and may have celiac disease What to challenge with Diet containing gradually increasing amounts of gluten Final amount will vary according to patient sensitivity Minimum of 10 g gluten day (four slices of bread-one slice has 2.25g) Maximum of as much gluten as tolerated Standard is four slices whole wheat bread a day Depends on duration of GFD, amount of gluten in challenge Use serology and symptoms as a guide to timing the EGD with biopsy Even if patient remains asymptomatic and seronegative, EGD with...

Genetic Testing

As discussed HLA studies indicate that most celiacs possess the extended haplotype, DR3-DQ2, or, less often, DR5 7-DQ2. Some celiac patients have DR4-DQ8. Virtually all celiacs bear one of these three haplotypes, which has led to the development of new assays for diagnosis and screening. PCR assays to detect a restricted set of HLA antigens (HLA DQ2 and DQ8) are available and can be helpful in defining those at risk of developing celiac disease. Although the prevalence of these HLA haplotypes is approximately 35 of the North American population, essentially celiac disease occurs only in the subset bearing at least one of these two genes. Thus, such testing can be useful in determining who should undergo a gluten challenge and also for screening family members.


Although continued ingestion of gluten is the most frequent cause of non-responsive celiac disease, other considerations include associated or complicating conditions (small bowel bacterial overgrowth, carbohydrate malabsorption, microscopic colitis) or an incorrect initial diagnosis. Failure to respond to a gluten-free diet or recurrence of symptoms on a gluten-free diet, particularly in an older patient, should also prompt a search for lymphoma provided that ingestion of gluten has been excluded as the cause of the symptoms. Refractory sprue is a presentation of celiac disease characterized as being unresponsive to dietary therapy, usually requiring immune modulating therapy and associated with a poor prognosis 57 . A subset of these patients with a band of subepithelial collagen present in small intestinal histological specimens is referred to as having collagenous disease. Other variants include structuring or ulcerative forms. It is thought that chronic stimulation of T cells...


Substantial advances have been made in our understanding of celiac disease, including the development of non-invasive techniques that can aid in the diagnosis and management of this disorder. Areas for further investigation include the pathogenesis and immunogenetics of celiac disease, and its relationship to other autoimmune diseases. Observations of an increased incidence of celiac disease have been attributed to increased amounts and the timing of the introduction of gluten in the diet of infants, and these warrant further examination. There is also a need for optimizing screening and diagnostic strategies and improving management, including the possible development of wheat strains deficient in gliadin 86 . New therapies are being developed and tested, including methods to digest gluten to non-immunogenic substances 87, 88 , an inhibitor of zonulin and immunomodulatory therapies.

Sheila E Crowe MD

6 Diagnosis of Celiac Disease 8 Complications of Celiac Disease 9 Mortality Associated with Celiac Disease 10 Non-Responsive and Refractory Celiac Disease 11 Risk of Malignancy in Celiac Disease 12 Management Issues in Celiac Disease 13 Screening for Celiac Disease 14 Prevention of Celiac Disease Celiac disease, also known as celiac sprue or gluten-sensitive enteropathy, is a chronic disorder that is readily recognized when it presents in its classical form with diarrhea, bloating, flatulence, weight loss and evidence of malabsorption. However, non-gastrointestinal GI and non-specific GI manifestations are currently the more common presentations of this disease. Withdrawal of gluten from the diet results in a rapid clinical improvement and a slower but corresponding return of normal small bowel histology. Inappropriate T-cell responses to ingested gluten in genetically predisposed individuals result in the intestinal injury that characterizes celiac disease. The discovery that tissue...

Definitions of a Low Medium or High GI Food or Diet

The GI of foods can be modified by changing the nature of starch (e.g. increasing amylopectin or decreasing amylose or by combing starch with protein gluten ) altering cooking methods (e.g. reducing the extent of gela-tinization or cooling to prevent retrogradation) using larger particle or piece size, adding some acids such as those in vinegar and lemon juice adding soluble fibers such as psyllium, or by adding or substituting lactose, fructose, or sucrose for starch or glucose.

Clinical features

The disease may then progress to thickening of the upper jejunum together with enlargement of the mesenteric lymph nodes and the development of lymphomatous masses. Typically, the spleen is not involved and may even be small and fibrotic, as described in coeliac disease. Distal spread beyond the abdomen is uncommon 1649, 798 .

Recurrent Aphthous Ulceration

Although most cases of recurrent aphthous stomatitis are idiopathic, a minority are caused, or exacerbated, by deficiencies in iron, vitamin B12 or folate, and as such are potentially curable. Haematinic deficiencies are reported to be twice as common in patients with recurrent aphthous stomatitis compared with controls. The condition is often made worse by emotional stress. Occasional cases are said to be related to gastro-intestinal complaints such as coeliac disease, Crohn's disease and ulcerative colitis, but some of the data are conflicting 56, 164 . However, it is likely that in most instances any associations are secondary to haematinic deficiencies.

Radiographic and Other Studies

Upper GI series with small bowel follow-through. May suggest Crohn disease, celiac disease, or lymphoma. 4. D-xylose test. Abnormal in diseases involving small bowel mucosa (eg, Crohn disease, celiac disease, small bowel bacterial overgrowth, and regional enteritis). Reserve for workup of chronic or recurring diarrhea.

Epidemiology and aetiology

Intestinal T-cell lymphoma (ITL) is rare, accounting for only about 5 of all gastrointestinal lymphomas, and is normally associated with coeliac disease 305 . There is marked geographic variation in the incidence of ITL, with a high incidence in Northern Europe, reflecting the notion that ITL arises against the same genetic background as that predisposing to coeliac disease 753 . There is no clear sex predominance and in Europe, the median age at diagnosis is around 60 years 305, 424, 374 . In contrast, a small series of Mexican patients had a median age of 24 years and there was circumstantial evidence for a possible aetiological role of the Epstein Barr virus, which is absent in European cases 1552, 795 . Congenital or acquired immunodeficiency disorders are not known to be associated with ITL.

Prognosis and predictive factors

The clinical course is very unfavorable due to complications from peritonitis and malnutrition and later from progressive disease typically characterized by intestinal recurrences. The malabsorption due to underlying coeliac disease is detrimental to these patients, particularly when recovering from surgery or receiving multiagent chemotherapy 444 . Consequently, only one half of the patients is amenable to chemotherapy 8-25 305, 424, 444 . The small group of long-term survivors usually received chemotherapy and, interestingly, none had a previous diagnosis of coeliac disease 305, 444 .

Additional T Cell Stimulatory Peptides in Barley Rye and Oats

To date, T cell stimulatory peptides have been identified in the alpha- and gamma-gliadins as well as in the LMW- and HMW-glutenins (Molberg et al., 1998, 2003 van de Wal et al, 1998a,b Arentz-Hansen et al, 2000, 2002 Vader et al., 2002a,b, 2003a). With the exception of the omega-gliadins, all types of gluten molecules thus appear harmful for consumption by CD patients. Other cereals can also be harmful for CD patients, in particular barley and rye, while oats is often considered safe. We have therefore investigated the presence of potential T cell stimulatory peptides in these cereals. Database searches with the predictive algorithm XXXQXPQXPY readily identified peptides in the hordeins of barley and in the secalins of rye, including the T cell stimulatory peptide QQPFQQPQQPFPQ (underlined residues are modified by tTG) that is also present in gluten (Vader et al., 2002b). In contrast, this algorithm failed to score hits in the avenins of oats (Vader et al., 2002b). Subsequently, we...

Generation of Safer Foods for Patients

The identification of gluten peptides with T cell stimulatory properties allows the development of tests that can screen food for the presence of such peptides. For this purpose we have generated monoclonal antibodies to T cell stimulatory peptides from alpha- and gamma-gliadins (Spaenij-Dekking et al., 2004). Moreover, we are in the process of generating monoclonal antibodies to T cell stimulatory peptides from LMW- and HMW-glutenins. The alpha- and gamma-gliadin-directed antibodies are highly specific for sequences in gluten molecules. A competition assay has been developed with these antibodies that can simultaneously measure the presence of multiple gluten components (Spaenij-Dekking et al., 2004). As this assay is the first to detect T cell stimulatory peptides and as it can measure both intact gluten proteins and fragments thereof, it offers significant advantages over assays that merely measure gluten content. We have also tested the possibility to detoxify gluten by...

Pathophysiology of malnutrition

Secondary malnutrition can be caused by reduced intake of food, malabsorption, impaired nutrient utilization, and nutrient losses associated with chronic infection and many other clinical conditions as well. Examples include inflammatory bowel disorders, celiac disease, chronic anemia, renal disorders, and cystic fibrosis (CF). In both primary and secondary malnutrition, understanding of the relevant genetic mechanisms can be helpful in approaching the clinical manifestations. Genetic mechanisms of malnutrition that affect susceptibility to infectious disease include mutations affecting metabolism of the trace elements zinc, iron, and copper, and several vitamins as well as those underlying complex, inherited disorders such as CF and celiac disease. Primary malnutrition impairs immunity impeding host response to infection, but these effects are reversible with nutrient repletion. However, calorie and nutritional supplement alone cannot resolve the secondary malnutrition with organic...

Hypothesis for Disease Development

In an oversimplified view CD results from interactions between a large number of potentially harmful peptides in gluten with HLA-DQ molecules. The more HLA-DQ molecules are available, the more gluten peptides can be bound, the larger the chance that a gluten-specific T cell response is initiated. After initiation, HLA-DQ expression is upregulated, an inflammatory response and tissue damage occurs, leading to the release and activation of tTG, which, in turn, Figure 11.1. Release of intracellular tissue transglutaminase results in an amplification of the gluten-specific T cell response through the generation of gluten peptides that have higher HLA-DQ binding affinity. APC antigen-presenting cell tTG tissue transglutaminase HLA-DQ2(8) human leucocyte antigen-DQ2 or -DQ8. Figure 11.1. Release of intracellular tissue transglutaminase results in an amplification of the gluten-specific T cell response through the generation of gluten peptides that have higher HLA-DQ binding affinity. APC...

Future Research and Perspectives

We now have detailed insight into the nature of the gluten-specific T cell response in overt disease. It is unclear, however, what triggers the disease. Nor is it known why the large majority of HLA-DQ2-and or HLA-DQ8-positive individuals do not develop the disease in spite of the fact that they continuously generate immunogenic HLA-gluten complexes in their intestine. It seems likely that this will occasionally trigger T cell responses. Apparently, whereas most individuals can control these responses, other progress to disease development. There is now strong evidence that, in addition to HLA-DQ, other genetic factors also play a role. Identification of those genes and unraveling of their mode of action represent important research goals for the coming years. Additionally, the influence of environmental factors cannot be ruled out. In this respect, it is important to point out that inflammation in the small intestine will lead to an upregulation of HLA-DQ molecules and this may lower...

Oil Water and Acidity

How, then, should pasta be cooked The first thing to keep in mind is that the proportion of proteins must be high. If hard wheat is not used then one must add eggs to develop the gluten network or else patiently work the dough and carefully roll it out, using enough water to hydrate the proteins so that they are able to bind together. Whatever its composition, pasta must be put into boiling water so that cooking time is reduced and loss of starch content minimized.

Functional Biotransformation

Some laccase substrates, such as phenols and thiols, are important components of various foods. Their modification by laccase may lead to new functionality, quality improvement, or cost reduction 81, 99 . For instance, laccases may oxidize and or cross-link the tyrosyl groups in myofibril proteins, leading to rheological changes of meat products 100, 101 . The ferulic acid units in arabinoxylans, pentosans, or pectins may be oxidized by laccase, leading to the gelling of cereal foods 102, 103 . Whey proteins and a-lactalbumin may be cross-linked by laccase in the presence of chlorogenic acid as a mediator. Gluten or other wheat components may also be affected by laccase in baking applications 104 .

Edible and Biodegradable Films

Weaknesses as packaging materials and vehicles for antimicrobial compounds, and is thus usually employed in combinations. Polysaccharide (cellulose, gums, starch) or protein (gelatin, corn zein, soy protein, whey, etc.) films are highly sensitive to moisture and are poor barriers to water vapor however, they exhibit suitable mechanical and optical properties. Films composed of lipids (waxes, lipids) have good water vapor barrier characteristics, but do not exhibit suitable mechanical and optical properties (are opaque and may be brittle). Wheat gluten and soy protein isolate films are effective O2 barriers at low relative humidity, but have limited vapor barrier ability. Addition of lipid components to protein-based films improves the characteristics of both materials by optimizing both permeability to moisture and structural strength. Polarity of these natural films will determine compatibility with a particular antimicrobial and application or incorporation method. As with synthetic...

Measlesmumpsrubella Vaccine

Disease prevalence data were collected by means of a postal questionnaire. The vaccinated group and their partners were asked whether they had, or had ever been told, by a doctor, that they had Crohn's disease, ulcerative colitis, coeliac disease or peptic ulcer disease. The unvaccinated group were asked about any condition that required regular medical supervision, the presence of any long-standing illness, disability, or infirmity, and details of all out-patient appointments and hospital admissions. Reports of Crohn's disease and ulcerative colitis were confirmed with the subject's physicians in the vaccinated and unvaccinated groups only. Crohn's disease and ulcerative colitis were reported more often among the measles vaccine group than among the control groups. The difference in the prevalence of inflammatory bowel disease was significantly higher in the vaccinated group when compared with the unvaccinated group. It was reported that, compared with the birth cohort, there was a...

Course and progression

In its active form -Da tocopherol - it acts as a membrane stabilizer and anti-oxidant. Deficiency occurs in chronic fat malabsorption (e.g. coeliac disease or cystic fibrosis) and results in widespread neurological disturbances -ataxia, ophthalmoplegia, seizures and corticospinal tract dysfunction. These are halted and often reversed by i.m. vit. E. It has been speculated that the antioxidant effect might make vitamin E a candidate for cytoprotection and repair within the nervous system. Studies in Parkinson's disease, multiple sclerosis and stroke are disappointing.

Malnutrition syndromes of childhood

Short bowel syndrome (congenital atresia or surgical resection), and inflammatory bowel diseases (IBD), which include ulcerative colitis (UC) and Crohn's disease (CD) are commonly associated with chronic malnutrition due to poor GI absorption. Bacterial infections may contribute to intestinal inflammation in genetically susceptible hosts. Malabsorption due to lactose intolerance and gluten-sensitive enteropathy are common causes of GI disease. Prolonged parenteral nutrition, while essential, often correlates with impaired immune responses due to loss of antigenic stimuli, caloric and micronutrient insufficiency. Change in normal flora can result in micro- Celiac disease is a genetically determined chronic inflammatory intestinal disease induced by an environmental precipitant, gluten, that often presents without clear GI symptoms. Celiac disease may be characterized by damage to the small intestinal mucosa caused by the gluten fraction of wheat proteins and similar alcohol-soluble...

Specific micronutrient deficiencies

Zinc deficiency is associated with primary immune deficiency disorders such as common variable immune deficiency or hypogammaglobulinemia, Di George syndrome and IgA deficiency, as well as other conditions including fetal alcohol syndrome, sickle cell disease due to hyperzincuria, celiac disease, enteritis and diarrhea. Zinc deficiency due to loss occurs in epider-molysis bulosa and in p-thalassemia due to chelation protocols required to remove excess iron secondary to chronic blood transfusion for anemia. Zinc deficiency inhibits Th1 cytokine responses, thymic hormone activity, and lymphopoiesis 1, 58, 68 . Acrodermatitis enteropathica, a genetic defect in zinc absorption, presents in infancy as skin lesions (acute dermatitis or hyperkeratotic plaques), diarrhea, alopecia, and increased susceptibility to infection, and is resolved with zinc supplementation 68 . Because zinc competes with copper for GI uptake, zinc supplements may induce copper deficiency, and may cause neutropenia 69...

Indications for the immunization of selected risk groups

Chronic diseases (such as asthma, chronic lung and heart diseases, congenital heart diseases, cystic fibrosis celiac disease diabetes and other metabolic diseases renal dysfunction, nephrotic syndrome and other chronic organ failures stable neurological conditions and Down's syndrome) in children and adults increase the risk from infectious diseases and are known to predispose to complications of infectious diseases.

Bowel Retraining for Anal Incontinence

The approach to patients with fecal incontinence begins with the identification of the etiology of the incontinence. Stool consistency, colonic transit, rectal sensation, rectal compliance, pudendal nerve integrity, and sphincter complex function all have a role in continence. Increased stool consistency and colonic transit can result from a number of medical illnesses and alterations in colorectal function. Those patients who do not have concomitant dysfunction of the pelvic floor are best treated with dietary manipulation and constipating agents. All patients should be encouraged to adhere to a well-balanced, high-fiber diet with adequate fluid intake. The addition of fiber to the diet aids in bulking and solidifying the stool to facilitate control in defecation. Some patients may benefit from dietary restrictions such as lactose-free or gluten-free diets.

World Made of Dough

In 1998, a team led by Jacques Guegen at the Institut National de la Recherche Agronomique station in Nantes showed that prolamins can bond with one another by means of dityrosine bonds. Tyrosine is an amino acid whose lateral chain is composed of a ch2 group, a benzene nucleus, and an -oh hydroxyl group. Shortly afterward, on the basis of this research, Katherine Tilley and her colleagues at the University of Kansas demonstrated the importance of dityrosine bonds in gluten. From bread dough at various stages of kneading, they extracted, dissociated, and chemically analyzed the gluten of the kneaded flour and found that concentrations of dityrosine increased during kneading. This raised the question of what role dityrosine plays in the formation of gluten. This discovery caused a stir among gluten chemists, for dityrosine bonds are commonly found in plant proteins, whose sequences and structures resemble those of glutens, as well as in resilin proteins, found in insects and On the...


A major factor in the development of small bowel adenocarcinoma is chronic inflammation. In particular, long-standing Crohn's disease with multiple strictures is associated with small bowel carcinoma 1016, 1223, 582, 1578 . One study showed that individuals with Crohn's disease have an 86-fold increased risk of adenocarcinoma of the small intestine 623 . Coeliac disease is another well recognized aetiological factor for small bowel carcinoma 116, 1354, 2141 . There is some epidemiological evidence that cigarette use and alcohol consumption are also risk factors 1339 . Carcinoma can develop in ileostomies in patients with ulcerative colitis or familial adenomatous polyposis (FAP) subsequent to colonic metaplasia and intraepi-thelial neoplasia in the ileostomy mucosa 1599, 558 . Carcinoma can also arise in


Ing factors, namely, an associated adenoma, coeliac disease, Crohn's disease, radiotherapy, previous surgery (notably pouch surgery and ileostomy), polyposis syndromes, Meckel's diverticulum, and intestinal duplication. Carcinomas may be polypoid, infiltrating or stenosing. Jejunal and ileal carcinomas are usually relatively large, annular, constricting tumours with circumferential involvement of the wall of the intestine 189 . Most have fully penetrated the muscularis propria and there is often involvement of the serosal surface 16 . Adenocarcinoma of the ileum may mimic Crohn's disease clinically, radiologically, endoscopically, and at macroscopic pathological assessment 745 . Although circumferential involvement can occur, duodenal carcinomas are usually more circumscribed, with a macroscopically demonstrable adeno-matous component in 80 of cases 966, 496 . Thus, they are often protuberant or polypoid, and the central carcinomatous component may show ulceration 1267 . Carcinomas...


HLA-DQ8 prefers negatively charged residues. Strikingly, tTG was found to selectively modify this peptide through conversion of the glutamine residues at the pi and p9 positions into glutamic acid (van de Wal et al., 1998b). As the result of this modification, a 100-fold less of the peptide was required for optimal T cell stimulation. Similarly, others identified an HLA-DQ2-restricted gliadin peptide and found that this peptide was only recognized after deamidation of particular Q residues, either as a result of chemical modification or treatment with tTG (Molberg et al., 1998 Sjostrom et al., 1998). In subsequent studies, a large number of gluten peptides have been identified that can stimulate T cells of CD patients (Arentz-Hansen et al., 2000, 2002 van de Wal et al., 2000 Vader et al., 2002a,b). It was also observed that some of those peptides cluster in regions that are resistant to degradation by enzymes in the gastrointestinal tract, resulting in highly immunogenic multivalent...

Dietary intervention

As the years passed, Joe's behaviour, concentration and hyperactiv-ity became unbearable but I would soldier on, trying desperately to keep the problems a secret for fear ofonce again being labelled a bad mother or worse. After Ben was born and diagnosed as autistic I came across the gluten- and casein-free diet and its reported benefits. I began to research in more detail and realized that foods were affecting Joe's behaviour too. Joe was already predominantly gluten- and casein-free but yet tiny bits of gluten were still in his diet. I read information on excito toxins such as monosodium glutamate (flavour enhancer) and aspartame (an artificial sweetener) and realized they were affecting Joe. After removing these from his diet, his behaviour changed so radically that I thought it would be plain sailing from then on. I was wrong It soon became apparent that Joe was reacting behaviourally to far more than gluten and casein, and while these were making a vast difference to all of our...

Biologic Assays

It is assumed that the highest quality protein is protein that supports maximal growth of a young animal. Because rats grow quickly and have limited protein stores and a high metabolic rate, deficiencies and imbalances in amino acid patterns in young growing rats can be easily detected in a short period of time. The protein efficiency ratio (PER) is defined as the weight gained (in grams) divided by the amount of test protein consumed (in grams) by a young growing rat over several days. Obviously, duration of diet, age, starting body weight, and species of rat used are important variables. Typically, 21-day-old male rats fed 9 to 10 protein (by weight) for 10 days to 4 weeks are used. In one series of tests, casein produced a PER of 2.8 soy protein, 2.4 and wheat gluten, 0.4. Clearly, a casein diet produced much better growth (2.8 g of carcass weight increase for every gram of casein consumed) than gluten (0.4 g of carcass weight increase for every gram of gluten consumed). Such an...

Life with Luke

Once Luke discovered his AS and subsequently embarked on the gluten- and casein-free diet, he decided to document how he felt and so his first book A User Guide to the GF CFDietwas born. As hormones hit him and he surged from childhood to adolescence, he searched for tips for AS kids in the areas he had difficulties with, and so decided to help others by writing his Freaks book. However, whilst his book is full of advice and tips to AS adolescents, Luke, like anyone giving advice, does not find it quite so easy to practise what he preaches

Treasured memories

If you ask my children to recall Easter, I know full well the one that will spring to their minds. It's not something I will forget easily either They often collapse into fits of giggles as they tell the tale, and relish the opportunity to recount it at the most inopportune moments. Easter is difficult in our house because the boys are on a gluten- and casein-free diet. There is always a great deal of tension as Joe gets angry and tries to steal the older children's Easter eggs. To compensate for their restrictions, I tend to go rather overboard by making treasure hunts and little games to play with their own special chocolate. One year we were all throwing sweets up in the air and seeing if any of us could catch them in our mouth. Whilst I played in one room with the boys, the girls did the same with chocolates and ofcourse I got the job ofmaking sure there was none on the floor that the boys could pick up later. As I scanned the floor for chocolate, I suddenly spied a stray...

Special diets

In our household I have Luke, Ben and Joe on the gluten- and casein-free diet, Joe and Ben allergic to eggs, Joe allergic to sesame and on the Feingold diet, Anna who would happily only eat sugary stuff, Matthew and Sarah whom I am sure would benefit from the GF CF diet (and refuse to go on it) and restrict themselves to pasta, cheese,


Diseases in the GI-tract may affect different factors important for drug absorption, and the effect on the overall pharmacokinetics is not always predictable. Inflammatory bowel diseases, such as Crohn's or ulcerative colitis, affect the absorption surface area and there are several reports on altered absorption in patients suffering from these conditions 6 . In celiac disease, associated with stunted small intestinal villi and alteration of gastric emptying and pH, the intestinal CYP3A4 content was decreased 7 . Changes in pH (e.g., achlorhydria or AIDS gastropathy) might delay and reduce the absorption of pH-dependent drugs such as ketoconazole 6 . Changes in GI-motility, by e.g., irritable bowel syndrome (small intestine), diabetes mellitus and nonulcer dyspepsia (stomach), and idiopathic constipation (colon), may affect the absorption of orally administered drugs by changing the rate of delivery, bioavailability, or mucosal absorption. For poorly absorbed drugs both...


Barley, whole, also known as Scotch barley, is nutritious and chewy and can be eaten alone or combined with brown rice or beans, or as a base for soup. Pearl barley is refined losing fiber and nutrient content. Basmati is a long grain Himalayan rice with a nutty, buttery flavor. White basmati lacks the fiber and nutrient value of brown basmati. Texmati and calmati are basmati hybrids. Buckwheat is gluten-free and suitable


The first infectious disease application of M-PCR was for the detection of HPV using either degenerate primers or consensus primers. Gregoire et al. (1989) used degenerate primers containing deoxyinosine at the variable base locations and showed that these consensus primers could detect all the HPV genotypes tested. Manos et al. (1989) also used degenerate primers, targeted to the LI gene instead of the El gene used by Gregoire et al., to detect several HPV genotypes recovered from the cervix. More recently, Vandervelde et al. (1992) used six pairs of HPV primers targeted to the E7 region to detect dysplastic changes in cervix tissue samples from Belgian women. Jullian et al. (1993) used HPV 16- and HPV 18-specific primers in an M-PCR assay to detect HPV in cervix tissue samples of women with normal cytology. Human T-lymphotropic virus (HTLV) types I and II have been detected in peripheral blood using type I- and type II-specific primers for three different genes (env, pol, and tax)...


Psoriasis is an acceleration in the growth of skin cells that results in patches of dry scaly itchy skin. The cause is unknown although it tends to run in families. Stress is often a trigger and gluten in foods or alcohol can precipitate the condition in some individuals. A sluggish liver may also be a factor. Getting sunlight is a common and effective remedy to alleviate symptoms. Antioxidants neutralize free radicals that play a role in inflammatory diseases like psoriasis.


Allergic response to gluten, characterized by proximal small bowel mucosal damage and subsequent malabsorption. Can occur at any time after gluten is introduced into the diet, from about 6 months to adulthood. Symptoms include diarrhea, abdominal distention and discomfort, lactose intolerance, poor growth, vitamin deficiencies, and iron-deficiency anemia.


Selective deficiency of IgA (or P2A or y1A according to previous terminology) was described by Giedion and Scheidegger (1957), Fudenberg et al. (1962), and West et al. (1962). Interestingly, these initial reports contained descriptions of patients whose symptoms presaged the clinical profiles of patients with IgA deficiency as defined in later, more extensive studies of the condition. Some of the patients, for instance, had respiratory infections and thus predicted the major clinical manifestation of IgA deficiency, that is, chronic upper and lower respiratory infections leading in the untreated state to bronchiectasis and respiratory failure. In addition, one patient had steatorrhea and malabsorption and was therefore representative of another symptom complex in IgA deficiency, a non-gluten-sensitive sprue-like syndrome marked by villous atrophy, malabsorption, and at times, intestinal nodular lymphoid hyperplasia. The origin of this symptom complex, initially described in depth by...

Why Gluten Free

Why Gluten Free

What Is The Gluten Free Diet And What You Need To Know Before You Try It. You may have heard the term gluten free, and you may even have a general idea as to what it means to eat a gluten free diet. Most people believe this type of diet is a curse for those who simply cannot tolerate the protein known as gluten, as they will never be able to eat any food that contains wheat, rye, barley, malts, or triticale.

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