Thursday, April 7, 2011

Cross Contamination

Why it is necessary to avoid cross contamination and why it is so hard to make others understand.
The issues created in celiac disease are at the molecular level, and it is the proteins of gluten causing the problem. Since it is an immune response, the smallest of particles can set off the reaction like in an allergic reaction. That is why some doctors will even refer to this as a gluten allergy. It is allergy-like in the cascade mechanism, but it is mediated through different pathways, and cells.

In celiac disease, a specific problem within the immune system develops in which ingesting certain types of grain proteins, (gluten) cause your body’s immune system to behave abnormally, including making antibodies against some of your own tissues. For this reason, celiac disease is classified as an autoimmune disease, meaning that the immune system attacks one’s own body.
The difference between Gluten reactions and allergies

THE ALLERGY CASCADE
• Allergies are an overreaction of the body's natural defense system that helps fight infections. The immune system normally protects the body from viruses and bacteria by producing antibodies to fight them.

In an allergic reaction, the immune system starts fighting substances that are usually harmless (such dust, pollen, or a medicine) as though these substances were trying to attack the body.

Allergens - An antigen that is the substance causing the reaction. Any substance that provokes an immune response is called an antigen.
The body produces specific antibodies to combat this “threat” even though it may be a harmless substance.

• The allergic cascade refers to the chain of events that takes place when an allergen triggers an allergic response. The cascade includes the allergic response, the cellular and chemical interactions that follow, and the symptoms that usually result, such as rash, itchy eyes, a runny nose, difficulty breathing, nausea, and diarrhea.

The key players in an allergic cascade include:

Allergens: Substances that the body perceives to be a threat. In response, the immune system overreacts by producing antibodies. IgE: (immunoglobulin E, a specific type of antibody that attaches to mast cells and basophils. IgE antibodies are like fuses to mast cells and basophils waiting to be “lit” by a specific type of antigen

THE CELIAC CASCADE
In the case of celiac disease, gluten proteins are the specific protein to which the immune system abnormally responds and thus it is gluten that is the antigen, and triggers celiac response. Gluten proteins, which are present in certain foods, enter into the mucosal lining of the small intestine where they are then taken up by macrophages. Through antigen presentation, the macrophages present these foreign proteins to the T-cells. The T-cells generate an immune response to gluten that involves production of inflammatory substances called cytokines which in turn attack and damage the intestine.

The role of tissue transglutaminase TTG
With celiac disease, the intestine becomes more permeable and excess amounts of gluten enter into the lining of the intestine. The gluten then encounters an enzyme called TTG that has been released from intestinal cells that have already been damaged in the first place. This enzyme then clips off a small piece of the gluten protein in a process called deamidation, this elicits an even stronger reaction from the T-cells when confronted.

A vicious cycle is now created in which gluten enters the lining of your intestine, T-cells respond and release cytokines which cause damage, this damage leads to a more permeable membrane and more gluten uptake which in turn leads to deamidation which stimulates the T cells which causes more cytokines to be released, which causes more damage which … on and on. The only way to halt the cycle is to remove gluten from the diet.
Once your body starts the antibody reaction those antibodies are going to start a cascade throughout the entire system. As an autoimmune mediated disease, it only takes a very tiny amount to start the reaction again, especially during early healing when you still have large numbers of antibody in your system.

Autoimmune diseases cause chronic problems and other diseases. Food allergies are caused by a different problem within the immune system and can lead to immediate catastrophic situations such as tongue, lip and throat swelling, bronchial spasm and anaphylaxis.
The gluten reaction time to onset after consuming the triggering food can be days to months and include GI symptoms, skin rashes, fatigue, muscle aches, joint pain, and neurological symptoms, whereas classic food allergy reactions tend to be immediate and short lived.

Because the reaction occurs on the molecular level, minute amounts of gluten can continue to cause big problems. Continuing to stimulate the autoimmune process can lead to further autoimmune diseases such as thyroid problems (hyper or hypo), diabetes, sjogrens, arthritis, osteoporosis, iron-deficiency anemia, neuropathy, asthma, and various dermatological problems.

Refractory Celiac - as many as one third of celiac patients may have refractory disease where the intestinal mucosa won’t heal. We don’t know how many of these people are simply being continually stimulated by cross contamination.

Chronic inflammation can lead to cancer – lymphoma, adenocarcinoma.

HOW MUCH GLUTEN IS TOO MUCH?
In general, research suggests that a daily gluten intake of less than 10 milligrams is unlikely to cause significant damage to the intestines in most people with celiac disease. Some gluten intolerant people will not be able to tolerate that much without having symptoms, as some people are more sensitive than others.

To understand how small an amount that is, think of medications. A very small pill can contain hundreds of milligrams and still be mostly filler material. A one-ounce piece of bread has approximately 3,515 mg of gluten, or 351 times the maximum daily amount that is safe for celiacs. This is how we get to the idea that even a crumb is too much.

Additionally, you have to consider the fact that even the strictest guidelines for gluten-free foods calls for them to be 20 ppm (parts per million) or less. So even if you are following the strictest of diets, you still can be getting a small amount of gluten per day. And there is a cumulative effect.

Even naturally gluten free foods often have cross contamination somewhere along the line. Certainly anything manufactured in a plant is subject to contamination and that contamination risk goes up if anything containing wheat, rye, barley or oats is manufactured in that same plant, or even worse, on shared lines.

In order for a product to be truly gluten-free, special handling is required at each step of the process—the growing, harvesting, milling, and processing of non-gluten grains. Shared equipment results in gluten contamination in the field, a manufacturing facility, a restaurant, or a home kitchen.
It is because of the low level of tolerance for gluten combined with the high risk for contamination that we admonish all gluten intolerants to be vigil about cross contamination. You are going to ingest some gluten every day. It is important to try to keep that level as low as possible to avoid disease progression.

CROSS CONTAMINATION RISKS
Family -why doesn’t my family get it?
There are many reasons family members are reluctant to get on board for you.
Lack of knowledge, what would you have thought about someone else having this disease before you ever heard of it. Most people had never heard of this disease until recently. It sounds crazy if you aren’t familiar with it and you never heard of such a thing while growing up. Wheat is the staple of our diet how weird is it that someone can’t eat wheat.
Try not to get defensive with your family and friends, remember, you had to take a crash course in gluten for survival and found it hard. Imagine how hard it is to learn, when you can’t even relate to the symptoms. They will never be as careful as you are, no matter how badly they want to protect you; they just are not used to living with it. Even if they made you a perfectly gluten-free meal, it is likely to get contaminated by someone if there is any gluten around.

Denial - They don’t want this to be real for you for many reasons. For parents it can be a defensive mechanism – not wanting to believe they gave such a disease to their child, or because if it is real for you, it might be real for them. This can apply to siblings and extended family. Food has strong emotional links, as you are probably well aware.
When a family member cannot eat the traditional family fare, it can feel like a form of rejection to the rest of the family.

Friends – Friends will often be willing to jump in with both feet. Proceed with caution here. Keep in mind how long it took you to learn the gluten free diet. Your friends, although very well meaning, are not likely to learn enough to keep you safe. You would really need to be involved while they learn how to cook for you. The few friends I now allow to cook for me will regularly call me to check on an ingredient. I had to cook side by side with them in order to teach them the intricacies of the diet.
You must take your disease seriously first. No cheating, be scrupulous about cross contamination yourself. Set a good example and your friends and family will hopefully come around.

Eating out-Try to eat at restaurants that have a gluten free menu. Judge the knowledge level of your server and proceed accordingly. Go through a list of reminders, even if they act like they know all about gluten intolerance.
No bread, no croutons, no crackers, dressing on the side or mix salad in a clean bowl. Clean the grill, no seasonings or sauces that are not gluten free.
Buffets – I recommend you avoid these if at all possible. Even if the food item is naturally gluten-free, the odds that another patron has contaminated it with the wrong serving utensil are high. I usually try to order from the menu, or get items that are served or made to order, such as an individually made omelet or carved roast beef.
It is always a risk to eat away from your own home, whether that is at a restaurant, family, or friend’s house. Try to limit your exposure.
Events - eat before you go or take something with you unless you know for sure there is something safe for you to eat.

Shared kitchens – This is the hardest situation of all. Fortunately, for me, my husband eats primarily gluten free with me. He does have some of his own cereal, bread and frozen dinners. However, everything I cook is gluten free. If a meal involves bread, it is gluten free bread for both of us. It is always my recommendation that the home be kept primarily gluten free. It is hard to go through life with this disease and not have a safe zone. My home is my safe zone. It is a rare exception for us to have other than a totally gluten-free meal in my house.

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