Building Tolerance

Dr. Bob Anderson, a gastroenterologist in Melbourne, Australia, is heading the research on a celiac vaccine. His work focuses on desensitizing patients by injecting them with gluten peptides, amino acids that gang up to produce the immune reaction. “The idea is if you give one injection, you will activate a response but if you repeat it, you can use it as a treatment,” he tells Allergic Living.

Anderson has focused on a treatment that would allow people to eat gluten because he knows it’s hard to avoid the protein, no matter how diligent you are. He points to research that suggests about half of patients who are following gluten-free diets still have substantial damage in their small intestines. Results from the Phase I safety trial with patients should be compiled and ready by the middle of this year.

Gluten-free Wheat

The effort to change the very makeup of wheat is centred at Washington State University. Dr. Diter von Wettstein, a professor in the department of crop and soil sciences is trying to neutralize the parts of gluten that cause the immune reaction in the first place. The goals are to produce a celiac-friendly wheat that contains lysine, an essential amino acid often deficient in the grain, which would help to maintain the wheat’s baking texture and elasticity when it was made into dough.

“Creating new cultivars of wheat, arguably the most important crop grown … will be of tremendous benefit not only for sufferers of celiac disease, but for all consumers of wheat and wheat products,” von Wettstein said.

Popping a Pill

Research to develop a celiac “pill” includes trials taking place at Leiden University in The Netherlands, where Dr. Frits Koning and his team are testing a drug derived from a common fungus that can be found on decaying vegetation. Known as an AN-PEP, it is thought to break down both the gluten proteins and the T-cell peptides in the small intestine, preventing an adverse reaction. They’ve found the enzyme to be safe in humans, but haven’t yet proved its effectiveness.

In Baltimore, Dr. Alessio Fasano and his team have developed a pill that, rather than break down gluten, prevents gluten particles from penetrating the lining of the small intestine. Fasano says to imagine the small intestine as a gated community, with a protein called zonulin opening and closing the gates. In people with celiac disease, the gate is left ajar. A person would take the drug before eating, to block the release of zonulin. Phase III clinical trials for the pill are on hold, as the biotech firm that was to conduct them is struggling with funding. Fasano may partner with a larger firm. “One of the best assets of a scientist is perseverance. This drug could potentially be the next blockbuster. You have to have faith.”

First published in Allergic Living magazine.
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A: Dermatitis herpetiformis is a skin disease caused by an intolerance to gluten. It is a form of celiac disease, the inherited autoimmune intestinal disorder that affects between one in 100 and one in 200 people worldwide. Gluten, found in the grains wheat, rye and barley, damages the small intestine and can also affect other body systems, such as the skin. About 10 per cent of celiacs will also have dermatitis herpetiformis (DH).

Although most people with DH have varying degrees of small intestinal damage, many will have no or few bowel complaints typically associated with celiac disease.

The DH skin rash burns and itches intensely. It is symmetrically distributed and usually found on the elbows, knees and buttocks. It also can appear on the back of the neck, upper back, scalp and hairline. Groups of small blisters will form that will erupt into small red lesions.

The condition typically appears between the ages of 20 to 45, but can occur at other times. It is most common in people of northern European descent and rare in Asians and African-Americans.

DH is often misdiagnosed as other skin conditions such as herpes, eczema, contact dermatitis, hives or psoriasis and treated with a variety of topical creams. The only way to diagnose DH is a skin biopsy from unaffected skin adjacent to blisters or lesions. A biopsy of the small intestine, normally used to diagnose celiac disease, is not essential if the skin biopsy tests positive for DH.

Next: Managing dermatitis herpetiformis

A: Quinoa (pronounced “keen-wah”) was a staple of the Incas who called it “the mother grain”. It is not actually a grain but a seed from a broad-leafed plant that is closely related to the weed lamb’s quarters and to spinach. Numerous varieties are grown in South America, and more recently in North America as well.

The quinoa seed looks like a cross between millet and sesame seed and is protected by a bitter, resin-like substance called saponin, which should be rinsed off before cooking. Some companies remove the saponin (like NorQuin brand) making it pan-ready, but quinoa is sold in several forms. (See below.)

It is a nutritious, gluten-free alternative that contains more high-quality protein than any other grain or cereal. In fact, its protein quality is comparable to that of dried skimmed milk. Quinoa is also high in iron, magnesium, phosphorus and zinc, and is a source of calcium, B vitamins and fibre.

How to Use:
• side dish instead of potatoes or rice
• in salads or pilafs, stuffing, casseroles
• thickener for soups, stews and chili

Cooking Tips
• rinse quinoa in cold water, drain.
• In a saucepan with a tight lid, bring 1 cup of quinoa and 2 cups liquid to a boil. Simmer for 15 minutes or until liquid is absorbed.
• let stand covered for 5 minutes.
Makes 3 cups.

How to Use:
• breakfast cereal
• substitute for up to 1/3 of the g-f flour in a cookie, muffin or bread recipe
• add to pancakes or waffles

Cooking Tips:
• add 1⁄3 cup flakes to 1 cup boiling water and boil 1 ¹⁄_² to 2 minutes, stirring frequently.
• remove from heat and cool. Then add chopped nuts, dried fruits and brown sugar.
• Or in microwave: high heat for 2 to 2 ¹⁄_² minutes.

How to Use:
• in baked items such as breads, muffins, pancakes, cookies, biscuits

Cooking Tips:
• has a slightly nutty, strong flavour so best combined with other g-f flours. Use no more than 25 per cent quinoa flour in recipe

How to Use:
• as a side dish or in salads

Cooking Tips:
• Follow directions on package.
Cooking time varies.

A: Celiac disease, also known as celiac sprue or gluten sensitive enteropathy, is an inherited digestive disorder affecting between one in 100 and one in 200 people worldwide. With this disease, specific proteins in wheat, barley and rye (collectively known as “gluten”) damage a person’s small intestine, so nutrients are not well absorbed. Gluten can also affect other parts of the body.

The symptoms are many, and vary in different individuals. They range from abdominal pain and bloating, to nausea, diarrhea or constipation, migraines, difficulty digesting lactose, weight loss or easy bruising. Since these symptoms can be common to other conditions, people with CD are often misdiagnosed with irritable bowel syndrome, lactose intolerance, chronic fatigue syndrome, diverticulosis (a condition of weakness in the walls of the colon), ulcers or allergies. Those with CD often suffer for years before a correct diagnosis is made.

Celiac disease can develop at any age, even in the senior years. It may be triggered by a viral or gastrointestinal infection, pregnancy, severe stress or surgery. If CD is untreated, it can cause nutritional deficiencies and increase the risk of osteoporosis, intestinal cancers, neurological disorders, infertility, as well as possible development of other autoimmune disorders. Celiac disease can occur in combination with Type 1 diabetes, auto-immune thyroid disease, autoimmune hepatitis, Down syndrome and Turner syndrome. If a person has any of these disorders and celiac symptoms or a family history of CD, that person should be screened for the disease.

Once a family doctor suspects CD, you should be tested. The doctor can order specific blood screening called tissue transglutaminase (TTG) and endomysial antibody (EMA). However, these tests are not 100 per cent accurate, the only way to be certain that you have CD is to undergo an intestinal biopsy. This procedure should be done by a gastroenterologist in a hospital outpatient setting. It is essential to get the testing done before starting on the GF diet, as this can interfere with making an accurate diagnosis.

Once the diagnosis is confirmed, the person with CD must stop eating all foods and ingredients derived from wheat, rye and barley. This is challenging as gluten is found in a wide variety of foods. Fortunately, many foods are naturally gluten-free, including plain meat, fish, poultry, eggs, legumes, nuts, dairy products, fruits and vegetables, and as well there are gluten-free flours and starches that can be substituted for wheat, rye and barley. And if you do prove to have CD, you will also come to appreciate the numerous gluten-free specialty products now on the market.

Celiac Symptoms

• abdominal pain, bloating and gas
• indigestion/reflux (heartburn)
• nausea and vomiting
• diarrhea, constipation or both
• lactose intolerance
• weight loss (CD can occur in obese individuals)
• chronic fatigue and weakness
• iron, folate and/or vitamin B12 deficiency
• other vitamin and mineral deficiencies
• bone and/or joint pain
• easy bruising of the skin
• swelling of hands and feet
• migraine headaches
• canker sores
• menstrual irregularities
• infertility (in both women and men)
• recurrent miscarriages
• elevated liver enzymes

Additional Symptoms in Children

• irritability and behavioural changes
• concentration and learning difficulties
• failure to thrive (delayed growth and short stature)
• delayed puberty
• dental enamel abnormalities

Charts from: Gluten-Free Diet by Shelley Case

Shelley Case, RD, is an international celiac nutrition expert, consulting dietitian and author of Gluten-Free Diet: A Comprehensive Resource Guide. See www.glutenfreediet.ca. Shelley Case is on the advisory boards of the Canadian Celiac Association, the Celiac Disease Foundation and the Gluten-Free Intolerance Group.The editors at Allergic Living additionally highly recommend her book Gluten-Free Diet, a vital resource for those interested in celiac disease and living gluten-free.

A: Gluten-free diets can be limited in variety, with white-rice bread, rice cakes, rice crackers and white rice as staples. Also, many commercial gluten-free products such as breads, cereals, pasta and flours are low in iron, B vitamins and fibre because they are made with refined flours and starches such as white rice flour, cornstarch, tapioca and/or potato starch. Following are some tips to help boost the quality of your diet.

Go for Enriched: Food regulations in Canada and the United States allow for enrichment of gluten-free foods. Check the ingredient listing to see if a product contains added vitamins and minerals.

Whole Grains, Fibre: Incorporate whole grains into your diet wherever possible. They contain the entire grain seed – the bran, germ and endosperm, which has more vitamins, minerals, protein and fibre than refined grains. Fibre can play a role in the prevention of coronary artery disease, diabetes and colon cancer. To prevent abdominal pain and gas, gradually increase your fibre intake and drink plenty of fluids.

Iron and Bones: Those newly diagnosed with celiac disease often have iron deficiency anemia because they have not been able to absorb adequate iron and other nutrients. A strict gluten-free diet will allow the intestinal villi to heal and nutrients to be absorbed properly. But the length of time for this varies, so it’s important to get plenty of iron-rich foods. Bone disease is common in those with celiac disease. You should eat three to four servings of low-fat milk products each day. If you are unable to consume enough dairy products, talk to your doctor or dietitian about calcium and vitamin D supplements.

Shelley Case, RD, is an international celiac nutrition expert, consulting dietitian and author of Gluten-Free Diet: A Comprehensive Resource Guide. See www.glutenfreediet.ca. Shelley Case is on the advisory boards of the Canadian Celiac Association, the Celiac Disease Foundation and the Gluten-Free Intolerance Group. The editors at Allergic Living additionally highly recommend her book Gluten-Free Diet, a vital resource for those interested in celiac disease and living gluten-free.

Makes 1 Loaf/24 Slices
Gluten-free

Ingredients

• 2 tbsp (30 mL) yeast (2 packages)
• 6 ^_1/2 cups (1.6 L) warm water
• 1 ^_1/2 lbs. (680 kg) teff flour (about 4 1/2 cups or 1 L)

Method

1. Dissolve the yeast in 1⁄4 cup (60 mL) water.
2. Combine the teff flour, yeast and the rest of the water in a large bowl. Mix well. Ensure that no clumps are left at the bottom or side of the bowl.
3. Cover the dough with plastic wrap and let it ferment for 2 to 3 days at room temperature. (Those with sensitive stomachs may consider making the injera the same day rather than waiting for 2 to 3 days. It will have a slightly “sweet” taste but that is considered normal.)
4. Drain off the water that has risen to the top of the dough.
5. Gradually add fresh warm water to the dough, just enough to make a thin smooth batter (like pancake batter); mix well. Cover the batter and let it stand until it rises, approximately 10 to 25 minutes.
6. Heat a 10-inch (25 cm) skillet or frying pan until a drop of water bounces on the pan’s surface.
7. Scoop about 1⁄3 cup (85 mL) of the batter and pour it into the pan quickly. Swirl the pan so that the entire bottom is evenly coated. Cover the pan quickly and let the injera cook for 1 to 2 minutes. (Injera does not easily stick or burn.) Remove the cover and wait for a few seconds. It is cooked when bubbles or “eyes” appear all over the top. If your first try is undercooked, cook the next one a little longer or use a smaller amount (1⁄4 cup or 60 mL) of batter. Do not turn the injera over in the pan. Use a spatula to remove the cooked injera and place it on a clean towel.
8. Let the injera cool and then stack on a serving tray. Do not stack hot as they will stick together.
9. Continue making the injera until the batter is finished.
10. Injera should be soft and pliable so that it can be rolled or folded like a crêpe or tortilla. Properly cooked, injera will be thinner than a pancake but thicker than a crêpe.

Nutritional Analysis
1 serving = 1 slice

Calories: (kcal) 105
Carbohydrates: (g) 21
Dietary Fiber: (g) 2
Fat: (g) 1
Protein: (g) 4
Iron: (mg) 2
Calcium: (mg) 54
Sodium: (mg) 7

Shelley Case, RD, is an international celiac nutrition expert, consulting dietitian and author of Gluten-Free Diet: A Comprehensive Resource Guide. See www.glutenfreediet.ca. Shelley Case is on the advisory boards of the Canadian Celiac Association, the Celiac Disease Foundation and the Gluten-Free Intolerance Group. The editors at Allergic Living additionally highly recommend her book Gluten-Free Diet, a vital resource for those interested in celiac disease and living gluten-free.

A Following a strict gluten-free diet can be challenging whether you’re away from home or in your own kitchen. While it’s not necessary for everyone in the household to go on a gluten-free diet or to eliminate gluten-containing items entirely, there are a number of ways to ensure your safe food doesn’t become contaminated with gluten. Here is some advice on how to store and prepare food in a gluten-aware kitchen.

Storage

• Keep all gluten-free products in separate containers.
• Use bright stickers to label everything that is and should remain gluten-free. Or purchase “gluten-free” stickers from the Canadian Celiac Association’s website.
• Have a separate spot in your cupboard and refrigerator for the gluten-free foods.
• Store gluten-free flours and grains in your cupboard above gluten-containing foods. Flour dust and bread and cracker crumbs can easily end up on or in gluten-free containers and boxes if you’re not careful.
• Buy your own containers of items such as butter, peanut butter and jam. Label them “gluten-free” to prevent other household members from dipping crumby knives from toast and sandwiches into a container.
• Use squeeze bottles for condiments such as ketchup, mustard and mayonnaise.

Preparation

• Have your own toaster. Or, use a toaster oven, with a rack that can be removed and thoroughly washed. Another option is to buy reusable toaster bags for gluten-free bread that can be placed in a regular toaster. (You may purchase them online, such as at ElPeto.com’s “store”.)
• Make sure the counter area you will be using is freshly washed and free of crumbs or flour dust. Have a separate cutting board that is only for gluten-free items.
• Thoroughly scrub pots, pans and utensils that have cooked other foods before using with gluten-free foods. It’s a good idea to have a separate set of utensils and other items for gluten-free baking (e.g. wooden spoons, sifter, bread machine).
• Don’t boil gluten-free pasta in the same water that cooked gluten-containing pasta. Have a separate colander to drain gluten-free pasta, as it is difficult to remove traces of pasta from a colander.
• Use separate utensils (knives, lifters, serving spoons, tongs) when preparing and serving gluten-containing and gluten-free items.

With a bit of planning and a lot of labeling, you can safely eat gluten-free alongside the rest of your family.

Shelley Case, RD, is an international celiac nutrition expert, consulting dietitian and author of Gluten-Free Diet: A Comprehensive Resource Guide. See www.glutenfreediet.ca. Shelley Case is on the advisory boards of the Canadian Celiac Association, the Celiac Disease Foundation and the Gluten-Free Intolerance Group.  The editors at Allergic Living additionally highly recommend her book Gluten-Free Diet, a vital resource for those interested in celiac disease and living gluten-free.

Gluten-free foods are popping up everywhere and the gluten-free diet is being promoted for everything that ails you. In order to separate the “wheat from the chaff” let’s look at the facts.

Celiac Disease
Gluten is a protein found in wheat, rye and barley. For those with celiac disease, gluten damages the lining of the small intestine causing a wide range of symptoms such as bloating, abdominal pain, diarrhea, constipation, gas, fatigue, migraines, depression, mouth ulcers, and bone and joint pain. Left untreated, the disease can lead to osteoporosis, anemia, infertility and even cancer. The only current treatment for celiac disease is a strict gluten-free diet for life.

Gluten Sensitivity
Recent research has revealed that some people may have non-celiac gluten sensitivity (GS). This condition can result in gastrointestinal symptoms such as bloating, gas and diarrhea (which also can occur in celiac disease). However, GS does not lead to nutritional deficiencies or the development of other complications. The prevalence of GS is unknown and the only way to diagnosis it is by ruling out celiac disease and wheat allergy. If tests for these are negative, a trial gluten-free diet, along with a symptom diary, may help to determine whether GS is causing the symptoms. Like celiac disease, the treatment of GS is a strict gluten-free diet.

Wheat Allergy
For those with wheat allergy, consumption of wheat triggers the release of IgE antibodies from various cells in the body. This causes an allergic reaction, with symptoms that can include hives, tingling of the mouth, abdominal pain, vomiting or diarrhea and a drop in blood pressure and breathing difficulties, which can be life-threatening in some cases. It is essential to eliminate wheat but, with an allergy, the other gluten-containing grains, rye and barley, can be consumed (as long as there is no “may contain” warning about the presence of wheat). The good news is that many children will outgrow a wheat allergy.

Autism Spectrum Disorders
The gluten-free, casein- free (a protein found in milk) diet, also known as the “GFCF diet”, has been advocated for those with autism spectrum disorders (ASD). Anecdotal reports from parents claim that the GFCF diet improves their child’s communication skills, reduces or eliminates gastrointestinal symptoms and/or improves their overall well-being. However, there is limited scientific evidence supporting the use of the diet for ASD. A recent report in the medical journal Pediatrics recommended that further research needs to be conducted, as only one placebo-controlled study of  the GFCF diet in 15 children with ASD has been published. This study did not find any differences in measures of severity of ASD symptoms, communication and social responsiveness in those on the diet.

Nevertheless, the Pediatrics report also indicated there is a possibility that a subgroup of individuals with ASD may respond to various dietary interventions, which is why well-designed studies over an extended period of time are essential to answer the questions. As the GFCF diet is complex and difficult to follow, especially since many children with ASD are picky eaters and have other food sensory issues, it is critical that families work with a registered dietitian to prevent nutritional inadequacies if they choose to put their child on the diet.

Weight Loss
A gluten-free diet has also been recommended by celebrities and others for weight loss. This is ironic because many processed gluten-free foods are higher in sugar, fat and calories. Healthy gluten-free whole-grains such as amaranth, buckwheat, millet, quinoa, sorghum, teff and brown rice can be part of a weight loss diet, but eating entirely gluten-free is not necessary, and can also be quite expensive.

Bottom Line
Individuals with celiac disease and gluten sensitivity need to follow a strict gluten-free diet for life. Whether the diet should be used for other conditions is controversial. Regardless of the health concerns, it is important to incorporate more nutritious gluten-free whole grains in the diet because many gluten-free packaged foods are made with refined flours and starches which are low in iron, B vitamins and fibre. Also it is essential to consult with a registered dietitian with expertise in the gluten-free diet to ensure that your diet is not only healthy, but safe. For more information see www.glutenfreediet.ca.

Shelley Case, RD, is an international celiac nutrition expert, consulting dietitian and author of Gluten-Free Diet: A Comprehensive Resource Guide. Shelley Case is on the advisory boards of the Canadian Celiac Association, the Celiac Disease Foundation and the Gluten-Free Intolerance Group. The editors at Allergic Living additionally highly recommend her book Gluten-Free Diet, a vital resource for those interested in celiac disease and living gluten-free.

A: Eating enough fiber is very important for people with celiac disease. Dietary fiber is the part of whole grains, fruits, vegetables, nuts, seeds and legumes (dried beans, peas and lentils) that cannot be broken down by the digestive tract.

Fiber helps maintain regular bowel movements, often a cause of trouble for people with celiac. Some celiacs suffer with diarrhea before their diagnosis, but the intestinal damage heals after they are on a gluten-free diet. The diarrhea stops, but at times, constipation develops.

Other celiac sufferers may have experienced constipation prior to diagnosis, and find it gets worse once they’re on a gluten-free diet. In both cases, the constipation is a result of eliminating the foods they used to eat with high fiber: wheat bran, whole wheat breads and cereals.

Unfortunately, many gluten-free foods are made with starches and refined flours that are low in fiber, such as white rice flour, tapioca starch, corn starch and potato starch. The good news is there are many excellent gluten-free alternatives to whole wheat and wheat bran that are high in fiber.

Next: List of flours and fiber content

A: It has been said many times: breakfast is the most important meal of the day. It not only helps improve mental and physical performance but provides many key nutrients, such as iron, B vitamins and fibre. Although traditional breakfast foods are often made with gluten-containing grains, these items can also be purchased or made from non-gluten grains, such as amaranth, buckwheat, corn, flax, millet, quinoa, rice, sorghum, soy and teff.

Gluten-free breakfast ideas

• Cold cereals: some good options are puffed amaranth, corn or rice; GF corn flakes; GF rice cereal; GF granola (look for granola from Enjoy Life Foods and Ener-G Foods).
• Hot cereals: can be made with cornmeal, corn or millet; grits; cream of buckwheat; cream of rice, oatmeal,* quinoa and teff.
• Toasted GF bread, bagel or English muffin with peanut butter or cheese spread. • GF pancakes or waffles** with fresh or frozen fruit. (Look for a gluten-free pancake/waffle mix or ready to eat frozen waffles, e.g. Van’s toaster waffles.)• GF muffin** with yogurt and fruit.
• French toast with GF bread. (Warm bread in microwave to aid absorption of the egg mixture.)• Toasted GF bread with eggs.
• Omelette (chopped green or red peppers, onions, shredded cheese) and leftover fried potatoes.
• GF pizza.
• Fruit smoothie. (Try milk or non-dairy substitute if you are also lactose intolerant; fresh or frozen fruit; honey or sugar and ground flax.)

* Commercial oat products are contaminated with wheat, rye or barley. It is important to choose pure, uncontaminated specialty oat products from companies such as Cream Hill Estates or FarmPure Foods (see Allergic Living Spring 2007 for more information about oats in the gluten-free diet).
** It is not possible to simply substitute gluten-free flours in a regular muffin or pancake recipe. The Complete Gluten-Free Cookbook by Donna Washburn and Heather Butt has many healthy recipes to choose from.

High-Fibre Hot Cereal

This quick, heart-healthy breakfast is packed with fibre and omega-3 fatty acids. Add a spoonful of brown sugar, chopped nuts and/or dried apricots or raisins for more flavour and extra nutrients.

3 tbsp (45 mL) flax seed meal (ground flax)*
3 tbsp (45 mL) cream of brown rice hot cereal (look for El Peto, Bob’s Red Mill or Lundberg)
1 1/3 cups (320 mL) water
Dash of vanilla

1. Combine the first 3 ingredients in a medium-to-large glass bowl.
2. Cook on high in a microwave for 3-4 minutes, or until thick and creamy. Stir in vanilla.
3. Serve with brown sugar, nuts and/or dried fruits.* As flax is very high in fibre, it is important to introduce it in small portions until tolerated. Start with 5 tbsp hot cereal and 1 to 3 tsp of ground flax, then gradually increase.

Variations: Substitute creamy buckwheat hot cereal or Bob’s Red Mill Mighty Tasty Gluten-Free Hot Cereal (made with whole grain brown rice, corn, white sorghum and buckwheat) for the brown rice hot cereal.

From Gluten-Free Diet by Shelley Case, Expanded Edition, 2006 See www.glutenfreediet.ca
Shelley Case is a consulting dietitian and author. She is on the advisory boards of the Canadian Celiac Association, the Celiac Disease Foundation, and the Gluten-Free Intolerance Group. The editors at Allergic Living additionally highly recommend her book Gluten-Free Diet, a vital resource for those interested in celiac disease and living gluten-free.