Guest Articles
From CeliacLinks Post Card Issue #2, February, 2002
Trigger Needed for Celiac Disease
Celiac Disease, often referred to as a mysterious malabsorption syndrome, is thought to be triggered in genetically susceptible individuals when they eat grains. For most patients, it is felt that a trigger, perhaps an illness, perhaps diet, or perhaps a virus--may also have been involved and link to the onset and actions within the body for this syndrome we commonly know as celiac disease.
Human adenovirous 12 ]Ad12] infection is thought to be the trigger that sets off the autoimmune chain reaction that causes the syndrome. The epidemiology of Ad 12 is unknown, however. For most cases of celiac disease, only stringent dietary restriction remains as the present known treatment.
Selected researchers continue to feel that virally encoded protein sequences play a role in the initiation of celiac disease. There is likely an immunologic cross-reaction between the virus and the alpha-gliadin.
From a study of the late 80s and early 90s, one researcher indicated the likelihood that the disease seems to involve immune mechanisms but the role of antibodies and the T-cells in producing the damage to the surface of the small intestine is not clear.
It's those amino acids that appear not to have their ducks in order! The study indicates that the amino acid sequences shared by alpha-gliadin and the Ad12 protein can function as an angiogenic determinant [seed or seedcase within a gene to make it possible for the illness to develop]. This is thought to be the case for antibody recognition and may also be the case for T-cell recognition.
Do
most celiacs have a realization of the trigger for their condition? Probably
not. Many of us, however, may know the blood line from which we inherited
the potential for development of the disease. Most of us learn early
on--the benefit and "cure" we find in a strict prescription
diet. 
From CeliacLinks Newsletter Issue # 3, March 2002
Celiac Disease: A Brief Background
About a century and a half ago, Samuel Gee described the clinical features of celiac sprue in children. A Dutch pediatrician, Dicke, astutely observed that some of his patients who had done well during the time of food rationing during World War II, became ill again after being provided cereal grains for their diet.
Soon afterward, Dutch researchers, Van de Kamer and Weijers, showed that the alcohol soluble component, [the gliadin component] of the water insoluble protein of wheat, produced a fat malabsorption in patients with celiac sprue. The peroral intestinal mucosal biopsy technique soon came into use and lead to the confirmation of the characteristic microscopic changes we now associate with celiac sprue. It then became clear that the celiac sprue disease of children and the non-tropical sprue condition in adults were the same illness.
Just how gluten interacts with the damages of the mucosa remains obscure, but there are several mechanisms implicated. The clinical features of celiac disease may vary widely from patient to patient and may give the appearance that there are in reality celiac diseases present instead of one format or presentation for celiac disease. The classical presentation of celiac disease most often includes diarrhea, flatulence, weight loss, and fatigue but those symptoms are variable from one patient to another and may all be present or all may be absent. Malabsorption may appear in the absence of GI symptoms such as diarrhea. Celiac disease is often reviewed in patients with unexplained iron deficiency anemia, folate deficiency, or metabolic bone disease.
There are well-established associations between celiac sprue and dermatitis herpetiformis, insulin dependent diabetes mellitus, and selective IgA deficiency. Associations have been postulated between celiac sprue and IgA nephropathy, ulcerative colitis, thyroid disease, primary biliary cirrhosis, and sclerosing choleangitis. Many patients with these conditions share HLA types with celiac disease and the presence of any symptoms or findings suggestive of malabsorption should prompt an evaluation for coexistent celiac sprue.
The diagnosis of celiac sprue hinges largely on mucosal biopsy and an unequivocal clinical improvement after gluten withdrawal is required to establish the diagnosis with or without repeat mucosal biopsies. In cases where there remains doubt, gluten challenge and repeat biopsy may be used.
The
present known treatment for celiac sprue involves a gluten-free diet. This
sounds simple, but can be a great challenge for selected patients since wheat
products are ubiquitous and added to many processed foods in our western
diet. Many patients must experiment for long periods of time to find the
dietary selections that will fit the needs of the disease and their particular
series of malabsorption problems; those patients that are sensitive to
minute amounts of gluten, can readily identify the onset of symptoms such as
diarrhea, abdominal cramping, and bloating when they stray from their
prescription diet. One lapse from the diet can cause major mucosal damage
that can last months. Selected celiac patients may have secondary
intolerances such as lactose and trehalose intolerance along with sensitivities
which are unique to them at this time and in a particular stage of their version
of the illness.
Enriching Foods Naturally
While some future crops will be genetically modified, Gary Gardner, professor of horticulture science and coordinator of the Center for Plants and Human Health, University of Minnesota, believes the nutritional disease-fighting properties of natural foods can be boosted through smarter agricultural production. Better lighting or temperature controls, for example, might spur the growth of cancer-preventing glucosinolates in watercress, a common salad ingredient.
"We're not looking for a magic pill. We want to find out how we can enrich the concentration of these compounds in foods you already eat so that what you eat is certifiably healthier for you in the prevention of disease.
"The good news is, since
watercress is basically a greenhouse crop, its production can be varied on a
commercial scale quite easily--you can change the lighting condition, the
temperature, the water conditions--so if tests are successful, there's not a
barrier to selling it. Consumers won't worry, because it's not chemically
treated or genetically modified."
Source: Minnesota, May/June 2002, p 36.
New Traits in Familiar Foods
The genome sequences for three types of plants have already been mapped, and more are coming says Dr. Ronald Phillips, professor of agronomy and plant genetics, University of Minnesota.
"Plant genetics is undergoing a paradigm shift: In the past we worked on single genes and single traits one at a time. But with genomic technologies, we can look at all the genes of an organism at one time and see what genes are controlling particular traits and which ones interact with each other.
"We've gone from the days
when, if we wanted envision creating some new trait in a plant, we had to know
that it already existed in a related plant. With the present knowledge and the
breadth of being able to transfer genes, we can determine what kind of trait
might be useful to have in a plant and we can figure out how to engineer
it. If we want vitamin A produced in rice, we can think, What will
it take to make that? Someday we'll be able to put together combinations
that will result in improved nutrition, anti-carcinogens, or vitamins in a way
that we've never been able to before.
Source: Minnesota, May/June 2002, p 38.
Handling Ecosystem Havoc
As the world gets smaller, we may face increasing problems from species that hop fences and ecosystems. Consider the recent history of figs and the wasps that are essential to their pollination. According to George Weiblen, assistant professor of plant biology, University of Minnesota, ornamental fig trees line many of the avenues and roadways in the state of Florida.
"But most are exotic species that have been taken from India, Africa, and Southeast Asia. Without their pollinating wasps, they can't reproduce. In recent years, however, the wasps have somehow been transported from their range in their native continents and found their hosts in Florida. The fig trees have started reproducing, causing native birds to feed on the fruits and disperse seeds into natural vegetation. What was once a benign ornamental is now a horribly invasive exotic wreaking havoc on forests and wetlands in the state.
"This is a perfect
example of how dramatic environmental changes are taking place around us all of
the time, and no one can predict what's going to happen where. Even
botanists in Minnesota have seen species that seemed incapable of growing in the
state 50 years ago now doing well, while plants that were once native to the
state of Minnesota are increasingly rare.
Source: Minnesota, May/June 2002, p 39.
New Labels to Show Country of Origin, Not Content
By September 2004, grocery shoppers will know what country provided the beef, pork, and chicken they put on their tables. Same for fish, peanuts, fruits, and vegetables.
For that, shoppers who like to know such things can thank the 2002 farm bill adopted earlier in the month of May 2002 by the Congress.
But not everyone is thankful, and the 10-year political war that got the provision into the farm bill is not over. Next comes a rule-making process at the U.S. Department of Agriculture, which is required to have a voluntary labeling system in place in September of 2002 and a mandatory system in place by September 2004.
"We foresee a major battle in the rule-making, because those who are opposed will attempt to minimize the impact," said Bill Bullard, chief executive officer of the Montana-based R-Calf United Stock Growers Association, which led the fight for labels on beef.
The country-of-origin provision in the farm bill requires that U.S.-labeled meat be from animals born, raised and slaughtered in the United States.
Food products that are included in processed foods, such as frozen dinners, are exempt from the requirement. The law also does not apply to food sold by restaurants or served by institutions such as hospitals.
The fight over regulations already is under way. Secretary of Agriculture Ann Veneman said that the USDA could consider using a "North American" designation on labels, as suggested by the Canadian Cattlemen's Association, rather than a United States designation.
The National Farmers Union said North American-origin labels should not be an option.
"Now that the law is enacted, we will continue to work to make sure it is implemented as written," said Dave Frederickson, the group's president.
The labeling issue is particularly sensitive among Canada, Mexico, and the United States, which are working under a free-trade agreement. Although some proponents saw it as a consumer's right-to-know issue, others made no secret of their desire to give U.S. products an edge over foreign products.
"For the first time, U.S. producers will be able to engage in true market competition with their products," Bullard said. "Presently, without labeling, the beef offered to consumers in nothing but a generic product."
It is this competitive motivation that concerns Canada and could lead to challenges under free-trade agreements, said John Masswohl, agriculture counselor at the Canadian Embassy in Washington.
"We have our people in Ottawa going though the farm bill as a whole, looking to see where there might be things that could be challenged, Masswohl said.
Canada does not want its name put on a label by default, Masswohl said. For example, he said, many pigs are born in Canada but when they are sold they spend nearly all of their life in the United State, eating U.S. grain before being slaughtered at U.S. plants.
"We would be concerned if someone started calling that pork, a product of Canada," Masswohl said. "We feel the Canadian designation has value, and it should genuinely be a product of Canada.
The USDA must also determine how the livestock industry is going to keep track of where every critter came from and what path it took through the process.
"We do know it's going to be a complex program to segregate the products, and we don't have a mandatory animal identification system." siad Janet Rile, spokeswoman for the American Meat Institute, which represents the packing industry.
Grocers are perhaps the most concerned with how the new rules will work.
"We are not opposed to country-of-origin labeling," said Fritz Stehlik, an Omaha attorney whose family owns Normal Food Stores in Nebraska City, "but whatever costs there are in complying with it will go right back to the consumer."
Under the new law, all of the responsibility for accurate labeling, as well as the liability for fines for non-compliance, falls on food retailers. "I think that may be a little unfair," Stehlik said.
The Food Marketing Institute, whose members are grocery stores, opposed country-of-origin labeling, especially a provision that allows fines of up to $10,000 a day for violations.
"We're in a tough spot here," institute spokeswoman Kate Coler said. "It sound like an easy idea, but it is very complicated. The rules are going to have to be very clear."
The new labeling law gives retailers options about how to inform the public of the country of origin, including the use of labels, stamps, marks, placards or signs on a display bin.
In the future, Coler
said, customers may even eat labels that have been sprayed on with an
edible product.
Source: Omaha World-Herald, May 26 2002, Business Section D, p 1.
Wildrice
Wildrice is an aquatic grass revered by Native Americans in the Lake States and New England of the U.S. and in Canada. The only cereal grain native to the United States, this delicacy is Minnesota's state grain. In the 1950s, University of Minnesota plant scientists began studying hundreds of alternative crops, including wildrice. At the same time, interested farmers in northern Minnesota began to form a cultivated wildrice industry to meet increased demand.
Researchers were challenged in taming the wildrice plant to make it suitable for paddy production. There were limitations of planting, caring for, and harvesting an aquatic species. The seed head "shatters" when ripe, is sending the precious crop into the water. Plants in natural stands mature at widely different times so several harvests must be made. And, the seed is not viable unless it is stored in conditions similar to a lake bottom.
Nevertheless, by 1964 selections were successfully grown in University of Minnesota paddies in St. Paul. Since then, nine varieties of paddy wildrice have been developed, each with improved production or disease-resistance characteristics.
Today there are two wildrice communities. Native Americans hand-harvest wildrice by traditional methods from canoes and using flails to dislodge the grain, which is labeled "lake grown." Commercial producers in paddies grow U of M varieties where specialized combines do mechanical harvesting. Minnesota produces over 6 million pounds of "paddy grown" wildrice, and much of it goes to food processors that market it in blends with white rice.
Interestingly, recent DNA analysis shows that white rice and wildrice have some common ancestry, contrary to earlier thinking that these species evolved separately in Asia and North America. [This is new information for the celiac community as well as the general public; it is then a correction that needs to be made for our thinking and for our print information resources].
Much of the U.S. wildrice research takes place at the University of Minnesota's North Central Research and Outreach Center at Grand Rapids, where results are shared with growers and others interested in this unique crop. Nets cover the paddies to protect the research from birds. Wildrice beds, lake or paddy, are home to a wide variety of insect, aquatic, waterfowl, and amphibious species.
"Purple Petrowski"
is the newest wildrice variety from the U of M Agricultural Experiment Station,
with a natural maroon and gold color scheme. It has high resistance to
shattering and lodging, produced high yields, and is moderately resistant to a
major fungal disease common to rice. Source:
Food for Life, University of Minnesota Experiment Station, College of
Agricultural, Food, and Environmental Sciences, University of Minnesota, c
2001.
Flax Fights Cancer . . .
Study Confirms Cancer Prevention
The cancer-fighting benefits of an ancient seed--flax--are receiving new attention--thanks to a study involving 32 postmenopausal nuns from the Order of St. Benedict near St. Cloud, Minnesota. The women added 5, 10, or no grams of ground flax seeds to their daily diets. Nutrition professor Joanne Slavin and graduate students analyzed urine and blood samples to measure the impact on each subject during the 21-week study supported by the National Cancer Institute and the Agricultural Experiment Station.
The results demonstrated an increase in protective estrogen levels, which may prevent some hormonally-related cancers, such as cancers of the breast and uterus. Flax is rich in lignans--chemicals that act like the female hormone estrogen in the human body. The phytoestrogen--"phyto" means "plant"--helps the body fight against disease by replacing protective estrogen.
Soy has similar qualities says Slavin, but a little flax goes a long way. In the study, five grams a day [about a tablespoon] had a good impact, with 10 grams showing only slightly better results. For comparative effects, a greater amount of foods containing soy would have to be consumed.
A registered dietician, Slavin is committed to helping people get phtytochemicals through foods. "Ground flax is fairly easy to put into foods, especially breads and cereals. In the study, seeds were ground and then stored in the freezer because the flax meal oxidizes fairly quickly. The women put it on cereal or stirred in into yogurt. Since then, research has shown even when ground flax is baked into bread, the lignans were still viable," she said.
Flax is sold in several forms. Flax oil--the edible version developed at the University of Minnesota--provides one of the Omega-3 acids proven to prevent cancer. The seeds themselves have laxative properties, but are not as digestible as ground seeds. Slavin cautioned against a trend toward isolating the phytoestrogens--both from soy and from flax--and selling it in tablet for. "As a food, flax has fiber and phytochemicals. We're not sure what compound in flax gives it the health benefits, so for now it's best to eat flax as a food rather than as isolate lignans."
Although the Greeks and Romans knew the tiny purplish seeds as a healthy food, in modern times flax has been relegated to animal feed status. Slavin wants to promote the benefits of flax, and welcomes recent publicity in the Chicago Tribure and the Twin Cities' Star Tribune." We can add flax to our diets so easily, and because it is a safe food that has been consumed for years and years, there doesn't seem to be a down side," she says.
The nuns agree. Many of them reported that they felt better and would continue adding flax to their diets.
Celiacs interested in
obtaining flax in the form of flour can do so through a number of commercial
food resources. Flax in breads, puddings, on yogurt, in salad dressings
and gravies is a common methodology for adding the suggested one-tablespoon of
flax flour per day to the regular prescription diet for celiacs. When
making a purchase of breads from a commercial resource, ask for breads
containing flax flour. Comment: Note that selected celiacs
have reported diarrhea as a side effect when including large amounts of flax oil
in the diet. On follow up of four cases, all were taking four or more flax
oil capsules per day--a pattern not recommended nor suggested by the company nor
found to be acceptable to the physician consult.
The researcher, Dr. Joanne Slavin, is in the Department of Food Science and Nutrition, College of Human Ecology, University of Minnesota.
Source: Minnesota Science, Vol 54, No 1, Spring 2002, Agricultural Experiment Station, University of Minnesota.
Interesting Observations
Leon H. Rottmann
[From CeliacLinks, Vol 1, No 8, August 2002]
Many patients with the condition of dermatitis herpetiformis appear to have mild intestinal lesions but have no intestinal symptoms.
Over 80 percent of patients with the skin disease of dermatitis herpetiformis also have at least latent celiac disease, whereas only relatively few patients with celiac disease have dermatitis herpetiformis.
The administration of one of the sulfones such as dapsone often relieves the skin itching associated with the skin lesions of dermatitis herpetiformis, but does nothing for the lesions of the gut.
Informal surveys indicate that only about 60 percent of celiac patients are able to make the decision to adhere to a strict gluten-free diet. For some few of those patients, attitude and acceptance of the condition of celiac disease may be the greater illness.
We tend to omit the reality that rice contains a gluten, oryzenin, but that it is a non-toxic gluten with gliadin-containing amino acids in a not-toxic order.
Diseases such as diabetes mellitus and abnormalities of thyroid function have been well described in association with celiac disease. Immune mechanisms may also represent the common link between these conditions and celiac disease.
The wide differences and the many differing variabilities [variances] among celiac patients is an important consideration for both treatment [definitions for diet] and research generalizations made on and for patient subjects.
There are only two protein groups that are composed of gluten: the gliadins, which are soluble in alcohol/water solutions; and the glutenins which are not soluble in alcohol/water solutions, but are soluble in some salt solutions.
"Once a sprue, always a sprue" is a hard line. There isn't a chance to grow out of the disease; there isn't yet a pill that will change things. Nothing known to medical science at this time will provide a cure. There is no cure to negate the intolerance. There is only monitoring of symptoms and the recommended plan of action--lifelong adherence to the gluten-free diet.
Some families which have active celiac disease in their blood line may also have active cases of Crohn's disease, Whipple's disease, Sjogren's syndrome, multiple sclerosis, lupus, infectious arthritis, sinusitis, variations of allergic rhinitis, and higher than normal reactions to specific odors.
When the label says "gluten-free" it's still best to get a listing of all of the ingredients along with an identification of fillers, preservatives, colorings, binders, flavoring agents, etc. which may not be listed on the label. Make your own evaluation and arrive at a decision that you know has been well researched and that has included all of the calculations you know are necessary when reasoning out if the question if a commercial product is okay for inclusion in your version of the gluten-free diet.
We spend so much of our time looking for answers about celiac disease when in reality, we do not yet know what questions we are to ask.
Order of who is on first base: or, the power struggle in the 3-ring circus known as celiac disease. First the diet gets you; then you need to turn around and get the diet; last, you need to get you. [the last--taking charge of yourself with appropriate self-management, may be the most challenging effort].
Bone diseases that complicate celiac disease include osteomalacia, a softening of the bones; and osteoporosis, a porous condition of the bones related to aging. Either or both may be problems for the celiac patient. And in both cases, both are a problem of malabsorption--the base of celiac disease and thus may be a critical part of the overall problem. Monitoring for bone problems with appropriate prevention and follow-up needs to be included in medical reviews and evaluations for most celiac patients. Hip X-rays may exhibit the presence of Losser's zones in the pelvis, a pseudo-fracture form of osteomalacia. Patients need to be pro-active and discuss the potential of bone problems being included with their particular version of the celiac condition.
The frequency of Type I diabetes mellitus is increased in patients with celiac disease. An NIH report lists a 2 percent frequency [1/74%] and several studies from medical journals represent up to 4.1 percent of diagnosed diabetes patients also have the gene match potential and/or have active celiac disease.
All celiacs run fewer risks if
they can maintain a lifelong abstinence of the gluten-containing grains in
addition to the special needs which may be represented for them--beyond the
details of their version of the gluten-free diet.
Who are the Heroes and Zeroes--in Your GF Diet Plan?
[Source: CeliacLinks, vol 1, #9, Sept 2002]
A number of long-term celiacs who make contact with Celiacs, Inc. are doing well on the diet and seem to have moved on into a lifestyle that fits the illness, the needs of their version of the prescription diet, and appear not to have taken on any new symptoms or conditions. There is one exception, however--they are overweight and have been overweight since getting onto the gluten-free diet.
What to do? A number of dietitians are offering the following solution. Don't stint on fruits and vegetables. Pick lean sources of protein. Limit your fat intake. They are telling us to look for the nutritional value in foods that we expect to eat at the same time that we review if that food is gluten-free before making it a selection for our own personal prescription diet.
People who have followed this sensible advice have lost weight. But too many of us appear to be getting only part of the message. Those persons who are wolfing down fat-free cookies and 4-grain bagels with sugar sealers in the name of better health are growing ever more corpulent. And this pattern has been fuel for the controversial theory: Carbohydrates make you fat. A diet rich in fat will slim you down.
And, of course, the debate over carbs and fats has been simmering for decades, it is not a new kid on the scene. It is driven in no small part by diet doctors and food companies with book sales at stake. But a part of the latest round in the nutritional slugfest began in mid-summer of 2002 when the cover of The New York Times magazine pictured a larded slab of beef with a pat of butter on top, alongside the provocative title, "What if Fat doesn't make you Fat?"
For anyone who just wants to drop a few pounds, the dueling prescriptions of dozens of plans can be hopelessly confusing. But they needn't be. Marion Nestle, nutrition expert of New York University likes to say, "It's the calories, stupid." Just eat fewer of them than you burn off, and you'll lose weight. And you don't have to adopt a trendy diet to do that. Just forget about the war between fats and carbs and focus instead on nutritional value. Don't pay attention to those 4-color magazines at the checkout counter--pay attention to common sense, the nutrition expert advises.
The truth likely is that no food group, whether it is fats or carbs, is made up entirely of heroes and zeroes. Of course, you can renounce fat for carbs and gain weight. But the only carbs you really need to restrict are the refined ones--foods made with white sugar and flour, ranging from your favorite sodas to sugary cereals. And, of course, there could be more additions for this list. It is these kinds of processed foods, however, that fail to fill you up until you've eaten far too many calories. These foods contain little to no nutritional value. And they're absorbed quickly into the bloodstream prompting the body to unleash a surge of insulin that accelerated the conversion of calories to fat.
In contrast, fruits and vegetables are more densely packed. They are absorbed gradually enough to prevent sudden insulin spikes. And they satisfy much better, thanks to their higher fiber and fluid content. When you eat an apple, you have a filling snack of about 80 calories. When you chow down a few cookies, you can consume 600 or so empty calories before you know it.
As for fats, easing up makes sense if you're trying to slim down. Gram-for-gram, they contain more calories than either carbs or proteins. But that doesn't mean they are inherently bad. Just as broccoli has an obvious advantage over a can of Pepsi, the fat in salmon is far superior to that found in a slab of bacon or a serving of fries. The need, however, is to just forget the war between carbohydrates and fats and incorporate the best of both into your meals.
For the celiac, it is then a smart strategy to learn not only the basis of the gluten-free diet, but also to learn the basics of nutritional value of foods you are reviewing to include in your personal prescription diet. Then, you have taken your plan for self-management of diet intake to a level that is more likely to include more of your personal needs for lifestyle as well as improved weight management.
In the
Cook's Notes section of your spiral notebook with your listing of foods allowed
and not allowed for the gluten-free diet. Go through the foods allowed and
place an asterisk by those foods that will meet your personal needs for
nutrition and for the needs of the gluten-free diet. Highlight those
foods for your diet. Consider crossing out some of the foods that may
be the highest contributors to your weight situation, if being overweight is
indeed a problem for you at all. Or, let those foods be on your listing
for the Allowed foods for the gluten-free diet, but use them sparingly--and only
on days when you can "take a few more calories out with exercise than you
are putting in." Unless you take action, and work out a careful diet
plan with a selection of foods fitting you and your needs at this time in your
life, there may always be more zeroes than heroes in your diet
selections.
Hypo-parathyroidism Co-Existing With Celiac Disease
Abstract from Wortman, et al from the American Journal of Medical Sciences
Idiopathic hyp-parathyroidism [IH] is often an isolated disorder in adults, but
in children it is usually a component of the autoimmune polyendocrinopathy
syndrome. The authors describe aa patient diagnosed with isolated IH at
age 57 and with celiac disease at age 64. Testing of the patient's serum
show antibodies of the immunoglobulin G against gliadin. The circulating
immunoglobulins reacted with bovine parathyroid tissue, specifically smooth
muscle of the blood vessels and glandular cells, as detected by indirect
immunoflourescence. Testing of celiac disease positive sera showed similar
parathyroid reactivity. When the patient was placed on the gluten-free
diet, endomysial, reticulin, and gliadin antibodies decreased to undetectable
levels, which was parallel with disappearance of the parathyroid
immunoreactivity. The gluten-free diet also produced severe hypercalcemia
that responded to calcitrol dose. It is possible that in this case the
same antibody or antibodies may have caused hyp-parathyroidism and celiac
disease. We conclude that, as in the case of childhood-onset IH variants,
patients with late-onset isolated IH should be monitored for additional
endocrine and extra-endocrine autoimmune disorders. [Am
J Med Sci 1994:307[6]:420-427].
New Ideas About Halting Diabetes
by Anne Underwood
Are dramatic changes in lifestyle an effective way to deal with the disease?
[This article from Newsweek Magazine is included for the patients who have both celiac disease and diabetes; consider this article for some notes and ideas to discuss at your next visit with your physician.
When Neal Barnard was growing up in the 1960s, he witnessed the devastation of diabetes firsthand through his father, a physician who specialized in the disease. "I can't tell you now many people I saw going blind, suffering heart attacks and having their legs amputated," he says. Barnard's father had one treatment to offer patients--insulin. Now that Barnard is an M.D. himself, he's trying a different approach. He's putting patients on an aggressive vegetarian diet in the hope of actually reversing type 2 [adult-onset] diabetes. "I want to turn the clock back so that patients can go off diabetes medications," he says.
That may not be as farfetched as it sound. The famed diet doctor Dean Ornish has shown that a strict low-fat diet and exercise can reverse heart disease. Why not diabetes? A leading risk factor for Type 2 diabetes is obesity. As Americans girth has expanded, disease rates have spiraled. Today, 16 million Americans have this disorder, costing the United States $100 billion a year. But new research shows that diet and exercise can not only help prevent the disease, but also possibly delay its progression. "With the right diet and fitness framework, we might really be able to modify the course of diabetes," says Dr. Francine Kaufman, president of the American Diabetes Association.
Diabetes is a progressive disease, but lifestyle changes can help at every stage. People with diabetes have trouble regulating blood sugar levels. Normally, the naturally occurring hormone insulin helps move glucose out of the bloodstream and into cells, which need the sugar for energy. But in many obese adults--and increasingly, overweight teenagers--cells stop responding properly to insulin. Blood sugar build up and eventually damages blood vessels and other tissues. Although supplemental insulin and insulin-boosting drugs are needed in advanced diabetes, patients with mild cases can often normalize their blood sugar with diet and exercise. The ADA advocates a diet of whole grains, fruits and vegetables with smaller portions of lean meat, fish, and dairy.
But Barnard, an adjunct professor at George Washington University, contends that to see reversals in diabetes, more drastic steps are necessary. In a small pilot study, he put seven patients on a strict vegan diet. Patients derived 75 percent of their calories from carbohydrates in the form of whole grains, vegetables, fruit and beans. Meat, cheese, and eggs were off-limits, since some scientists believe their saturated fat and high calories increase insulin resistance. After 12 weeks, the vegan patients showed an average 28 percent reduction in fasting blood sugar versus a 12 percent reduction in the control patients who followed the ADA diet. "Most of the vegan group were able to reduce their medications," adds Barnard. "None of the controls did." But such a small trial is hardly conclusive, and Barnard is repeating the trial now in a larger group of 68.
Barnard did not include an exercise regimen in his study, because he wanted to isolate the effects of diet. But for people with diabetes, exercise is crucial; active muscles absorb glucose more efficiently. The combination of diet and exercise is more powerful than either one alone and may be even more effective than drugs, at least in preventing diabetes. A landmark trial of 3,234 pre-diabetic patients last year found that a low-calorie low-fat diet and moderate exercise--30 minutes five times a week--reduced new diabetes cases by 58 percent over a three-year period. By contrast the drug metformin, which boosts insulin sensitivity, reduced new cases by only 31 percent.
Even with diet and exercise,
not everyone will be able to roll back diabetes. After a certain point,
the body simply cannot produce enough insulin. In such advanced cases,
however, diet and exercise may still help prevent some of the worst effects o
the disease--heart attacks and strokes. The NIH is launching a 12-year
5,000-patient study to test the idea. If it proves successful, it would
not only reduce the nation's $100 billion burden, but also relieve untold human
suffering. [Source: Newsweek, January 20, 2003, Volume CXLI,
Number 3, p 56].
Celiac Disease: A Chronic Health Problem, Not a Chronic Illness
Celiac disease is a diagnosis that means a chronic health problem, not a chronic illness. It is a matter of therapy and self-management for the patient. The accurate labeling of gluten content in foods, quality control of the gluten-free diet, and a more reasonable control of cost factors for both the commercial developer and supplier of gluten-free foods and the patient consumer would greatly reduce the therapy problem.
Living gluten-free could be made much simpler with a unified support system directed to this specific health concern. It does nothing to help the celiac patient when foods are labeled gluten-free when this is not true. Because so many celiacs, both children and adults, are sensitive to peripheral sources and minute amounts of gliadin and gliadin peptides, a label that does not take all gliadin sources into account with a zero tolerance level provides harm and further confusion for the consumer. Gliadin-contaminated "gluten-free" products should be marketed as gluten-restricted rather than gluten-free.
A case in point: the results of 17 malignancy/lymphoma celiac disease studies representing 59 university-based authors all refer to the role of the gluten-free diet against malignancy and give further support for advising all patients to adhere to a strict gluten-free diet for life. The risk of lymphoma is defined as significantly increased in those persons taking a normal diet or a reduced gluten diet. Thus, the support for the protective role for the gluten-free diet with regard to malignancy or lymphoma complicating celiac disease.
The recognition that pharmaceutical preparations [both over-the-counter and prescription] may contain gluten is also of concern. Manufacturers should look to other sources for the excipient [the inert substance used as a vehicle for the drug], or at least ensure that their products are comprehensively labeled or that their consumer information sources have access to information for both health professionals and the consumer. And, in addition to the excipient, pay attention to the binders, extenders, coloring agents, preservatives, flavorings, sealers, packaging material, etc. that are or may be used with all medicaments.
At the present time, labeling legislation allows incomplete descriptions of food components and additives. Gluten can be found in all of these unexpected sources. In many cases, the composition of raw materials is not exactly known to the food manufacturer who may put together a commercial food product from several sources. [Starch is not starch is not starch when purchased in the market is a saying that is symbolic of many items purchased for the production of foods in the markets of our country]. The current rules and definitions are imprecise and lenient--for the market, for definition, and especially for the celiac patient.
Without a definition in the U.S. for toxic gluten content for celiac patients and without an acceptance of a zero level of gluten content in both foods and medications, even the commercial manufacturers for gluten-free foods accept variances and differing definitions of "what is gluten-free." Without a commonly held definition, there is no code or standard for the determination of "foods acceptable for the gluten-free diet." Manufacturers who follow the zero level of gluten standard are not rewarded. Manufacturers who slip in gluten content here and there or who have "their own well-developed definitions of what is gluten-free" are not reprimanded. Celiac patients who can follow a gluten-restricted diet disagree vehemently with the parents of children and the adult patients who become ill or develop symptoms on the ingestion of minute amounts of offending gliadin. Patients at any point in the continuum of gluten intolerance "know that they know" what is gluten-free. The reality is likely that each patient reflects a differing set of needs and also represents a different level of tolerance for toxic gluten. The result is often confusion for the patient and their associated monitors and those professionals within the community who serve them with food and medications.
Both physicians and pharmacists commonly offer prescription medications without concern for gluten content in extenders, binders, and preservatives. They cannot believe that a patient would ever question consuming a medication with a coloring agent based on lakes. Thus, the patient must be the moderator who will need to deal with both the lack of adequate information and the lack of regulations. All too often, even after extensive review of a prescription medication, the patient must learn through trial and error and will need to take on celiac symptoms and thus define that this product will not be tolerated.
Further complicating the puzzle are the dictates of the World Health Organization who through their Codex Alimentarius Committee that sits in Rome, Italy has guidelines stating that products containing greater than 0.3 percent protein from celiac-toxic trains cannot be labeled as gluten-free. With the influx of international foods and raw materials into the U.S. markets following these definitions, the celiac consumer must then add those products for review and most often rejection for inclusion in the zero gluten-free diet. At this point product laws, indices, and guidelines need to be rewritten to more accurately represent the health maintenance needs for the celiac patient. Our celiac population represents far too many children and adults who must follow a zero content of gliadin-offending grain-containing foods.
The gluten-free diet is simple but made complex without definitions, cooperation, and the acceptance of the many and differing needs of celiacs and the varying factors of the conditions of celiac sprue and dermatitis herpetiformis. Celiacs are a minority population that has not been able to do for themselves nor have they been able to work out within the regulatory community and our legislative bodies a plan of action that could be helpful to producers, manufacturers, suppliers, and to the patients who consume their products. We seem to have created islands of information here and there and are a part of series of cell groups of cooperating professionals, but have yet to formulate and develop a community--a community that recognizes the needs of the entire family of celiacs and a community in which the leadership will see fit to develop a unified support system that can attack the critical problem of quality control for the gluten-free diet.
Until celiacs, our
caretakers, our medical professionals, our many serving manufacturers and
suppliers, our legislators, or some interest group can put together "the
big picture" for the prescription diet for celiacs, the illness will remain
a critical, complex, and chronic health problem.
Source: CeliaLinks, Vol 2, Issue 2, February,
2003. Leon H. Rottmann.
Celiac Sprue and Diabetes Mellitus
The frequent association of celiac sprue [CS] and insulin-dependent diabetes mellitus [DM] which may be the interplay between genetic, hormonal, and immunologic factors has obvious therapeutic implications--and particular perspectives of self-management. A gluten-free diet may almost always improve the diarrhea in some celiac patients where the reason for diarrhea is underlying celiac sprue; the diet may also improve control of diabetes mellitus by normalizing the serum hormonal profile.
However, the association between celiac sprue and diabetes mellitus may present a problem in management. Diabetic diarrhea [due to visceral dysautonomia] or diabetic steatorrhea [due to bacterial overgrowth] may be difficult to differentiate from celiac sprue. Jejunal biopsy or determination of IgA reticulin-antibody is helpful in the differential diagnosis of diarrhea in such cases. In diabetic patients with coexistent CS, control of DM can be difficult.
Gluten restriction and the strict gluten-free diet may help in the better control of DM and for the relief from gluten reactions. On the other hand the standard diet for diabetics may include gluten-containing carbohydrates, which may then provoke and accentuate the exacerbation of CS. It is important to recognize the presence of DM when it coexists with CS and to recognize its causes and relationship to diarrhea and other symptoms of CS. In some cases of diabetic diarrhea and steatorrhea, the underlying abnormality may be an abnormal small bowel morphology, and the gluten-free diet would then be beneficial.
Early recognition of CS
is helpful to avoid poor response to gluten withdrawal, the potential for
intestinal lymphoma, and spleen atrophy. However, this generalization
appears to be more true for patients diagnosed late in life. Moreover, the
adherence to the gluten-free diet has a protective role against malignancy and
improves spleen function. Preventing complications is the major issue; for
the most part, it is the strict adherence to diet that meets the needs of both
CS and DM along with the unique idiosyncrasies which may be present for an
individual patient. Physician and patient monitoring added to a strict
self-management plan are the basics for the CS patient with DM.
Source: CeliacLinks Vol 2, Issue 1, January 2003.
Celiac Proctitis: A Note from Norway
An increased association of ulcerative colitis and celiac disease has been reported, have the results of several small-bowel studies in ulcerative colitis. Forty-two patients from a population of 438 patients with celiac disease had rectal biopsies. Fourteen of these showed inflammation of various degrees of severity, including three compatible with a diagnosis of ulcerative colitis.
The presenting complaint in 34 of these patients was diarrhea or steatorrhea. Twenty-seven patients had celiac disease diagnosed at the same time or after their rectal biopsy. The other 15 were previously diagnosed celiacs. Twelve of the 14 patients with abnormal rectal biopsy specimens were known to have subtotal/total villous atrophy at the time of the rectal biopsy.
Proctitis as seen in
these celiac patients had no unique features to differentiate it from proctitis
caused by other disorders. The diarrhea stopped in all patients on
commencement of a gluten-free diet, except in those with ulcerative
colitis. Proctitis is common in patients with celiac disease presenting
with diarrhea/steatorrhea. This study supports the finding of an increased
association of celiac disease and ulcerative colitis. [to the knowledge of
the authors, this was the first rectal biopsy study of a celiac population.
Source: Scandinavian Journal Gastroenterology,
Breen, et al. University Department of Medicine. Regional Hospital,
Galway, Ireland, pp 471-477.
Psychological Disturbance
From Panminerva Medica. It should not be forgotten that there is a reported association between celiac disease and schizophrenia. It is the observation of several physicians that there is a small number of patients with celiac disease who present with various psychiatric disorders. An example of this observation is a nun who was seen who was concerned that there was a television on her head that was telling her what to do. Following a diagnosis of celiac disease, it was gratifying when she reported that a gluten-free diet caused the television set to shrink and finally disappear.
It was some years later
that the convent in which she was living [by accident] reintroduced her to a
normal diet, which resulted in the return of the television set. It was
fortunate that the reintroduction of her gluten-free diet has once again
resulted in the disappearance of the television set.
Please Leave Home Without It
This is a reminder to office workers, carpool riders, frequent flyers, theater goers, [and the lady who sits beside me at church who wears the apricot fragrance]---all of you everywhere---that your perfume, cologne, and aftershave can trigger allergic and asthmatic reactions in susceptible people.
Be aware that the scent that appeals to you may totally overwhelm others. One person's perfume is another's poison.
Seriously consider not using a fragrance at work--or anytime you expect to be in a confined space.
Stop by a department store perfume counter and ask about the correct way to apply and reapply. One person's advice: "Spray the scent into the air and walk into it. "
Consider the
possibility of taking a morning and an evening shower, using a deodorant [if
allowed at all for the celiac patient] and save fragrances for your private
and personal life.
New
Soft Drinks in the Market
If
sugary soft drinks are designed to appeal to children, what are adults supposed
to drink? If Steve Hersch has his
way, they’ll reach for a more “mature” kind of soda, his. Hersch, age 37, is the founder of GUS [Grown-Up Soda], a new
line of less-sweet but intensely flavored sodas such as Dry Valencia Orange, Dry
Meyer Lemon, and Extra Dry Ginger Ale.
“When
you grow up, your taste changes,” says Hersch. “You want drinks that are
more flavorful. “ And GUS is
directed to the this taste change that Hersch finds in the “mature adult.”
And
he’s not the only soft-drink entrepreneur chasing this market. There’s also Tommy’s Naked Sodas that are all-natural
beverages made with cane sugar [as opposed to corn syrup that has sweetened
sodas since the late 1970s]. Tommy’s
orange actually tastes like an orange, and his lemon-lime is crisp and tart, not
sugary. Next is Fizzy Lizzy, a line
of natural beverages made using only fruit juices and seltzer.
While the taste may be more attractive to adults, the special fizzing may
really attract the adult who still has some “kid” left and will enjoy the
tongue delight of the fizz. Steap
Green Tea Sodas is a brand that is advertised [perhaps certified is the correct
term] as being organic. Steap’s
micro-brewed drinks come in such traditional flavors as cola, root beer, orange,
and lemon dew, but contain no additives or refined sugars.
These labels [new brands] are showing up at specialty food markets and at
health food shops.
But
are they okay for the celiac? At
this time that may remain a moot question.
With lots of natural flavorings, colorings, dyes, flavor enhancements,
natural preservatives, etc., etc., represented, perhaps the answer is already
in. It appears that there are
several substitutions and improvements that all sound good and make them
enticing; however, some of the same ingredients that commonly cause toxicity and
reactions for the celiac continue on the ingredient listings.
Eat
Your Sandwich Wrapper
A
new kind of sandwich wrapper not only keeps lunch fresh, it is represented as
being healthier, too. Chemists at
the U.S. Department of Agriculture have devised edible wraps in such flavors as
carrot, tomato, broccoli, mango, peach, apple, papaya, and strawberry.
The
wraps are made of pureed fruit or vegetables, mixed with vegetable oils to keep
them from dissolving into sandwiches and other foods.
“You can use a tomato or ketchup-flavored wrap on hamburgers when you
freeze them,” says USDA chemist Tara McHugh.
[see her excellent article in ChemMatters].
“When you defrost the meat, you can cook the whole thing wrap and
all.”
These
edible wraps are to be expected to be available on store shelves by the
end-of-the-year. And, they are
expected to be highlighted at health food stores.
Again, the question for use by celiacs.
I personally did not have a reaction to either tomato or strawberry
wraps. However, my sample was only
a few bites and those were taken without an entire sandwich.
A couple of questions remaining involve whether a preservative may need
to be added so as to extend shelf life or whether a sealed [canned] packaging
will be adapted such as that being used by ENER-G Foods with their gluten-free
breads will be adequate. Second,
whether a mix of “vegetable oils” may include one or more of the oils to
which selected celiac patients may have or develop a sensitivity or reaction.
Facsimile: (402) 553-3266
U.S. Mail:
Celiacs, Inc.,
PO Box 31144
Omaha, NE 68131
info@e-celiacs.org
Last Updated on 05.28.02 webmaster@e-celiacs.org