Do You Need Separate Cookware for Celiac Disease?

Maybe.  A recent abstract at 2019 NASPGHAN meeting addressing this issue was highlighted in Gastroenterology and Endoscopy News.

Link: Recommendations for Children With Celiac Disease Need Update

An excerpt:

In two related experiments, researchers from the celiac disease program at Children’s National Medical Center in Washington D.C., looked at whether, and how much, gluten could be transferred from contaminated cafeteria foods and school supplies to children’s hands, work tables and gluten-free food (abstract 656). The researchers also analyzed how effective different washing methods were at removing gluten contamination…

Ms. Weisbrod said she and her colleagues were surprised that using a shared toaster for both gluten-free and gluten-containing bread transferred minimal gluten (<5 parts per million [ppm] in most samples), as did playing with Play-Doh (median, 1.25 ppm). Both exposures were well below the 20-ppm threshold the FDA uses to consider an item gluten-free.

My take: The NASPGHAN meeting also featured a lecture by Alessio Fasano indicating that ~30%of patients with celiac disease had persistent disease due to poor adherence with a gluten-free diet and about 10% of patients with celiac disease are exquisitely sensitive to gluten.  So, while this small study indicates that gluten exposure may be lower than gluten threshold in many cases when sharing toasters, etc, I think more attention should be directed at strict gluten avoidance rather than trying to discern if some level of cross contamination may be acceptable.

Addendum: Cross-contamination results were later published with regard to three items -cooking pasta, use of toaster, and slicing a cupcake: Gastroenterol 20202; 158: 273-5.  The associated editorial (page 51) the authors state that they do not believe that concern about gluten cross-contact is overblown and state findings should be cautiously interpreted in light of small sample size and lack of investigator blinding.

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Drug Therapy for Celiac Disease

While a life-long gluten-free diet (GFD) is effective in most individuals with Celiac disease (CD), it is not effective in some. This could be related to cross contamination of food products, improper/inaccurate labeling and perhaps other factors as well.  As a consequence, there is a rationale for the development of medical therapy.  A recent study (Gastroenterol 2014; 146: 1649-58) has shown the ability of ALV003, a mixture of 2 recombinant gluten-specific proteases administered orally, to protect patients with celiac disease from gluten-induced mucosal injury in a phase 2 trial.

Methods: In a 6-week challenge study, adults with biopsy-proven celiac disease were divided into a treatment group with ALV003 (n=20) or a placebo group (n=21).  The 2.0 g gluten dose (equivalent to 1/2 slice of bread) for the study was determined after an optimization study (using 1.5 g, 3.0 g or 6.0 g of gluten (bread crumbs) in three divided doses).  Biopsies were taken before and after the gluten challenge.

Key finding:

  • No significant mucosal deterioration was observed in biopsies from the ALV003 group based on biopsies after the challenge period.  In contrast, the placebo group did have evidence of mucosal injury.

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What is Gluten-Free?

An excerpt from the National Foundation for Celiac Awareness Press Release:

NFCA Press Release about FDA Gluten-Free Labeling Rule

AMBLER, Pa. (August 2, 2013) – The National Foundation for Celiac Awareness (NFCA), a national non-profit organization dedicated to increasing diagnoses and improving quality of life for those with gluten-related disorders, is responding promptly to the U.S. Food & Drug Administration’s (FDA) final rule on gluten-free labeling by announcing new resources for gluten-free consumers to understand the federal regulations.

“For years, gluten-free labels have gone unregulated, putting our gluten-free community in danger,” said Alice Bast, President of NFCA. “We applaud the FDA for finally publishing a standard definition of gluten-free.”NFCA logo

The new regulations state that a food must contain less than 20 parts per million (ppm) of gluten in order to bear a “gluten-free” label. Researchers support less than 20 ppm as a safe threshold for a product to be consumed by individuals with celiac disease and other gluten-related disorders.

“Evidence-based research conclusively supports the 20 ppm level as a safety threshold for gluten-free products,” said Dr. Alessio Fasano, Director of the Center for Celiac Research at MassGeneral Hospital for Children in Boston. “We welcome the new FDA regulations, which will bring us in line with gluten-free labeling regulations for millions of people around the world.”

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Thanks to Kayla Lewis for forwarding the press release.


Expert review: Celiac disease

A recent article gives a concise expert update on Celiac disease (NEJM 2012; 367: 2419-26).

As this is an area that has been covered several times by this blog and is familiar to most of the followers, I will comment on a few issues that were particularly interesting to me.  Though, the review is thorough and a helpful reference on most aspects of celiac disease..

What is the gluten threshold?  In patients with celiac disease, a minimal degree of gluten contamination is difficult to avoid.  “The lowest amount of daily gluten that causes damage to the celiac intestinal mucosa over (the gluten threshold) is 10 to 50 mg per day (a 25-g slice of bread contains approximately 1.6 g of gluten).”  New regulations propose that foods which are labeled as gluten free have less than 20 ppm of gluten contamination.

When are intraepithelial lymphocytes increased in the duodenum?  The abnormal threshold is considered >25 per 100 enterocytes.

What proportion of celiac disease patients have been diagnosed?  According to a recent European study, only a small proportion (21%) of celiac patients are clinically recognized.

Best screening test currently? Anti-tissue transglutaminase (TTG) IgA antibody –both sensitivity and specificity are >95%.  Consider TTG IgG in patients with IgA deficieny or possibly deamidated gliadin IgG.

Potential complications of untreated celiac disease? Osteoporosis, impaired splenic function, neurologic disorders, infertility or recurrent abortion, ulcerative jejunoileitis, and cancer.

Biopsy needed? Usually, “although recent guidelines suggest that biopsy may not be necessary in selected children with strong clinical and serologic evidence of celiac disease.”

Population-based screening or case-finding?  At this time, population-based screening is not recommended.  Case-finding based on symptoms and screening of at-risk groups is recommended though this is likely to miss >50% of cases.

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