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Geisslitz S, Pronin D, Neerukonda M, Curella V, Neufang S, Koch S, Weichert H, Weber H, Börner A, Schuppan D, Scherf KA. Breeding from 1891 to 2010 did not increase the content of amylase/trypsin-inhibitors in wheat (Triticum aestivum). NPJ Sci Food 2023; 7:43. [PMID: 37612428 PMCID: PMC10447418 DOI: 10.1038/s41538-023-00219-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/08/2023] [Indexed: 08/25/2023] Open
Abstract
The prevalence of hypersensitivities towards wheat has increased in the last decades. Apart from celiac disease these include allergic and other inflammatory reactions summarized under the term non-celiac wheat sensitivity. One suspected trigger is the family of amylase/trypsin-inhibitors (ATIs), non-gluten proteins that are prominent wheat allergens and that activate the toll-like receptor 4 on intestinal immune cells to promote intestinal and extra-intestinal inflammation. We therefore quantified 13 ATIs in 60 German hexaploid winter wheat cultivars originating from 1891 to 2010 and harvested in three years by targeted liquid chromatography-tandem mass spectrometry combined with stable isotope dilution assay using specific marker peptides as internal standards. The total ATI content and that of the two major ATIs 0.19 and CM3 did not change from old cultivars (first registered from 1891 to 1950) to modern cultivars (1951-2010). There were also no significant changes in ATI distribution.
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Affiliation(s)
- Sabrina Geisslitz
- Department of Bioactive and Functional Food Chemistry, Institute of Applied Biosciences, Karlsruhe Institute of Technology (KIT), Adenauerring 20 a, 76131, Karlsruhe, Germany.
- Leibniz-Institute for Food Systems Biology at the Technical University of Munich, Lise-Meitner-Str. 34, 85354, Freising, Germany.
| | - Darina Pronin
- Leibniz-Institute for Food Systems Biology at the Technical University of Munich, Lise-Meitner-Str. 34, 85354, Freising, Germany
| | - Manjusha Neerukonda
- Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Valentina Curella
- Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Sibylle Neufang
- Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Sandra Koch
- Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Heiko Weichert
- Department of Molecular Genetics, Leibniz Institute of Plant Genetics and Crop Plant Research, Corrensstr. 3, 06466 Seeland/OT Gatersleben, Germany
| | - Hans Weber
- Department of Molecular Genetics, Leibniz Institute of Plant Genetics and Crop Plant Research, Corrensstr. 3, 06466 Seeland/OT Gatersleben, Germany
| | - Andreas Börner
- Genebank Department, Leibniz Institute of Plant Genetics and Crop Plant Research, Corrensstr. 3, 06466 Seeland/OT Gatersleben, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Katharina Anne Scherf
- Department of Bioactive and Functional Food Chemistry, Institute of Applied Biosciences, Karlsruhe Institute of Technology (KIT), Adenauerring 20 a, 76131, Karlsruhe, Germany.
- Leibniz-Institute for Food Systems Biology at the Technical University of Munich, Lise-Meitner-Str. 34, 85354, Freising, Germany.
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2
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Engel S, Klotz L, Wirth T, Fleck AK, Pickert G, Eschborn M, Kreuzburg S, Curella V, Bittner S, Zipp F, Schuppan D, Luessi F. Attenuation of immune activation in patients with multiple sclerosis on a wheat-reduced diet: a pilot crossover trial. Ther Adv Neurol Disord 2023; 16:17562864231170928. [PMID: 37384112 PMCID: PMC10293514 DOI: 10.1177/17562864231170928] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/03/2023] [Indexed: 06/30/2023] Open
Abstract
Background Western lifestyle has been associated with an increase in relapsing-remitting multiple sclerosis (RRMS). In mice, dietary wheat amylase-trypsin inhibitors (ATIs) activate intestinal myeloid cells and augment T cell-mediated systemic inflammation. Objective The aim of this study was to assess whether a wheat- and thus ATI-reduced diet might exert beneficial effects in RRMS patients with modest disease activity. Methods In this 6-month, crossover, open-label, bicentric proof-of-concept trial, 16 RRMS patients with stable disease course were randomized to either 3 months of a standard wheat-containing diet with consecutive switch to a > 90% wheat-reduced diet, or vice versa. Results The primary endpoint was negative, as the frequency of circulating pro-inflammatory T cells did not decrease during the ATI-reduced diet. We did, however, observe decreased frequencies of CD14+ CD16++ monocytes and a concomitant increase in CD14++ CD16- monocytes during the wheat-reduced diet interval. This was accompanied by an improvement in pain-related quality of life in health-related quality of life assessed (SF-36). Conclusion Our results suggest that the wheat- and thus ATI-reduced diet was associated with changes in monocyte subsets and improved pain-related quality of life in RRMS patients. Thus, a wheat (ATI)-reduced diet might be a complementary approach accompanying immunotherapy for some patients. Registration German Clinical Trial Register (No. DRKS00027967).
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Affiliation(s)
- Sinah Engel
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Münster, Germany
| | - Timo Wirth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Münster, Germany
| | - Ann-Katrin Fleck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Münster, Germany
| | - Geethanjali Pickert
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Melanie Eschborn
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Münster, Germany
| | - Samia Kreuzburg
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Valentina Curella
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefan Bittner
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Frauke Zipp
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Felix Luessi
- Department of Neurology and Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn²), University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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3
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Afzal M, Sielaff M, Distler U, Schuppan D, Tenzer S, Longin CFH. Reference proteomes of five wheat species as starting point for future design of cultivars with lower allergenic potential. NPJ Sci Food 2023; 7:9. [PMID: 36966156 PMCID: PMC10039927 DOI: 10.1038/s41538-023-00188-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/06/2023] [Indexed: 03/27/2023] Open
Abstract
Wheat is an important staple food and its processing quality is largely driven by proteins. However, there is a sizable number of people with inflammatory reactions to wheat proteins, namely celiac disease, wheat allergy and the syndrome of non-celiac wheat sensitivity. Thus, proteome profiles should be of high importance for stakeholders along the wheat supply chain. We applied liquid chromatography-tandem mass spectrometry-based proteomics to establish the flour reference proteome for five wheat species, ancient to modern, each based on 10 cultivars grown in three diverse environments. We identified at least 2540 proteins in each species and a cluster analyses clearly separated the species based on their proteome profiles. Even more, >50% of proteins significantly differed between species - many of them implicated in products' quality, grain-starch synthesis, plant stress regulation and proven or potential allergic reactions in humans. Notably, the expression of several important wheat proteins was found to be mainly driven by genetics vs. environmental factors, which enables selection and refinement of improved cultivars for the wheat supply chain as long as rapid test methods will be developed. Especially einkorn expressed 5.4 and 7.2-fold lower quantities of potential allergens and immunogenic amylase trypsin inhibitors, respectively, than common wheat, whereas potential allergen content was intermediate in tetraploid wheat species. This urgently warrants well-targeted clinical studies, where the developed reference proteomes will help to design representative test diets.
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Affiliation(s)
- Muhammad Afzal
- State Plant Breeding Institute, University of Hohenheim, Fruwirthstr. 21, 70599, Stuttgart, Germany
| | - Malte Sielaff
- Institute for Immunology and Research Center for Immune Therapy (FZI), University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Ute Distler
- Institute for Immunology and Research Center for Immune Therapy (FZI), University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immune Therapy (FZI), University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Stefan Tenzer
- Institute for Immunology and Research Center for Immune Therapy (FZI), University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - C Friedrich H Longin
- State Plant Breeding Institute, University of Hohenheim, Fruwirthstr. 21, 70599, Stuttgart, Germany.
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Reinmuth-Selzle K, Bellinghausen I, Leifke AL, Backes AT, Bothen N, Ziegler K, Weller MG, Saloga J, Schuppan D, Lucas K, Pöschl U, Fröhlich-Nowoisky J. Chemical modification by peroxynitrite enhances TLR4 activation of the grass pollen allergen Phl p 5. FRONTIERS IN ALLERGY 2023; 4:1066392. [PMID: 36873048 PMCID: PMC9975604 DOI: 10.3389/falgy.2023.1066392] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/12/2023] [Indexed: 02/17/2023] Open
Abstract
The chemical modification of aeroallergens by reactive oxygen and nitrogen species (ROS/RNS) may contribute to the growing prevalence of respiratory allergies in industrialized countries. Post-translational modifications can alter the immunological properties of proteins, but the underlying mechanisms and effects are not well understood. In this study, we investigate the Toll-like receptor 4 (TLR4) activation of the major birch and grass pollen allergens Bet v 1 and Phl p 5, and how the physiological oxidant peroxynitrite (ONOO-) changes the TLR4 activation through protein nitration and the formation of protein dimers and higher oligomers. Of the two allergens, Bet v 1 exhibited no TLR4 activation, but we found TLR4 activation of Phl p 5, which increased after modification with ONOO- and may play a role in the sensitization against this grass pollen allergen. We attribute the TLR4 activation mainly to the two-domain structure of Phl p 5 which may promote TLR4 dimerization and activation. The enhanced TLR4 signaling of the modified allergen indicates that the ONOO--induced modifications affect relevant protein-receptor interactions. This may lead to increased sensitization to the grass pollen allergen and thus contribute to the increasing prevalence of allergies in the Anthropocene, the present era of globally pervasive anthropogenic influence on the environment.
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Affiliation(s)
| | - Iris Bellinghausen
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Anna Lena Leifke
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
| | - Anna T. Backes
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
| | - Nadine Bothen
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
| | - Kira Ziegler
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
| | - Michael G. Weller
- Federal Institute for Materials Research and Testing (BAM), Berlin, Germany
| | - Joachim Saloga
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA
| | - Kurt Lucas
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
| | - Ulrich Pöschl
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
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5
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Liwinski T, Hübener S, Henze L, Hübener P, Heinemann M, Tetzlaff M, Hiller MI, Jagemann B, Surabattula R, Leeming D, Karsdal M, Monguzzi E, Schachschal G, Rösch T, Bang C, Franke A, Lohse AW, Schuppan D, Schramm C. A prospective pilot study of a gluten-free diet for primary sclerosing cholangitis and associated colitis. Aliment Pharmacol Ther 2023; 57:224-236. [PMID: 36266939 DOI: 10.1111/apt.17256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/02/2022] [Accepted: 10/08/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a progressive bile duct disease associated with inflammatory bowel disease (PSC-IBD). AIM To investigate whether patients with PSC-IBD benefit from a gluten-free and amylase trypsin inhibitor (ATI)-free diet (GFD). METHODS We performed a prospective clinical pilot study administering an eight-week GFD. The primary outcomes were colonic inflammation assessed by proctosigmoidoscopy, and liver stiffness (surrogate for fibrosis, inflammation and cholestasis) measured by transient elastography before and after GFD. Amongst the secondary (exploratory) outcomes were colonic mucosal and serum cytokine/chemokine changes, the intestinal microbiome and transcriptome dynamics, and shifts in serum markers of hepatic fibrogenesis. RESULTS Fifteen patients with PSC-IBD completed the study. The study did not meet its primary outcome: the endoscopic score and liver stiffness remained unchanged. However, the expression of pro-inflammatory mucosal cytokines and chemokines such as IL6, IL8, CCL2, and TNFα was significantly down-regulated. Two critical markers of liver fibrosis and matrix remodelling, thrombospondin-2 and -4, decreased significantly. The microbiota composition changed slightly, including a decrease in the pathogen Romboutsia ilealis. The intestinal transcriptome indicated a gut barrier improvement. Pruritus, fatigue, overall well-being, faecal calprotectin levels, and serum alkaline phosphatase did not change significantly. CONCLUSIONS This study did not demonstrate a clinical improvement with short-term GFD in patients with PSC-IBD. However, a gluten/ATI-free diet may improve biomarkers of intestinal inflammation and barrier function in these patients with associated changes in the enteric microbiota. Further investigation of the therapeutic potential of the GFD in PSC-IBD is warranted.
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Affiliation(s)
- Timur Liwinski
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Center for Affective, Stress and Sleep Disorders (ZASS), University Psychiatric Clinics (UPK) Basel, University of Basel, Basel, Switzerland
| | - Sina Hübener
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lara Henze
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Hübener
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Melina Heinemann
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus Tetzlaff
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie I Hiller
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bettina Jagemann
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rambabu Surabattula
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Diana Leeming
- Research and Development, Nordic Bioscience, Biomarkers and Research A/S, Herlev, Denmark
| | - Morten Karsdal
- Research and Development, Nordic Bioscience, Biomarkers and Research A/S, Herlev, Denmark
| | - Erika Monguzzi
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Bang
- Institute for Clinical Molecular Biology, Christian Albrechts University of Kiel, Kiel, Germany
| | - Andre Franke
- Institute for Clinical Molecular Biology, Christian Albrechts University of Kiel, Kiel, Germany
| | - Ansgar W Lohse
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology, Hamburg, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Schramm
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Shah A, Kang S, Talley NJ, Do A, Walker MM, Shanahan ER, Koloski NA, Jones MP, Keely S, Morrison M, Holtmann GJ. The duodenal mucosa associated microbiome, visceral sensory function, immune activation and psychological comorbidities in functional gastrointestinal disorders with and without self-reported non-celiac wheat sensitivity. Gut Microbes 2022; 14:2132078. [PMID: 36303431 PMCID: PMC9621048 DOI: 10.1080/19490976.2022.2132078] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Frequently, patients with functional gastrointestinal disorders (FGIDs) report intolerance of wheat products. We compared gastrointestinal symptoms, sensory function, psychiatric comorbidities, gut-homing immune cells, and duodenal mucosa-associated microbiome (d-MAM) in FGID patients and controls with and without self-reported wheat sensitivity (SR-NCWS). We recruited 40 FGID patients and 20 controls referred by GPs for treatment. Gastrointestinal/extraintestinal symptoms, visceral sensory function, psychological comorbidities, and SR-NCWS were assessed in a standardized approach. Peripheral gut homing T-cells (CD4+α4+β7+CCR9+/CD8+α4+β7+CCR9+) were quantified, and the d-MAM was assessed by DNA sequencing for 46 subjects. Factors of bacterial genera were extracted utilizing factor analysis with varimax rotation and factors univariately associated with FGID or SR-NCWS included in a subsequent multivariate analysis of variance to identify statistically independent discriminators. Anxiety scores (p < .05) and increased symptom responses to a nutrient challenge (p < .05) were univariately associated with FGID. Gut homing T-cells were increased in FGID patients with SR-NCWS compared to other groups (p all <0.05). MANOVA revealed that anxiety (p = .03), visceral sensory function (p = 0.007), and a d-MAM factor comprise members of the Alloprevotella, Prevotella, Peptostreptococcus, Leptotrichia, and Veillonella lineages were significantly (p = .001) associated with FGID, while gut homing CD4+α4+ β7+CCR9+ T-cells were associated (p = .002) with SR-NCWS. Compared to controls, patients with and without SR-NCWS show that there are shifts in the amplicon sequence variants within specific bacterial genera between the FGID subgroups (particularly Prevotella and Streptococcus) as well as distinct bacterial taxa discriminatory for the two different FGID subtypes. Compared to controls, both FGID patients with and without SR-NCWS have an increased symptom response to a standardized nutrient challenge and increased anxiety scores. The FGID patients with SR-NCWS - as compared to FGID without SR-NCWS (and controls without SR-NCWS) - have increased gut homing T-cells. The d-MAM profiles suggest species and strain-based variations between the two FGID subtypes and in comparison to controls.
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Affiliation(s)
- Ayesha Shah
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia,Translational Research Institute Queensland, Australia,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Seungha Kang
- Faculty of Medicine, University of Queensland, Brisbane, Australia,University of Queensland Diamantina Institute, Woolloongabba, Australia
| | - Nicholas J Talley
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, and Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Anh Do
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Marjorie M Walker
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, and Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Erin R Shanahan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia,Translational Research Institute Queensland, Australia
| | - Natasha A Koloski
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia,Translational Research Institute Queensland, Australia,Faculty of Medicine, University of Queensland, Brisbane, Australia,College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, and Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Michael P Jones
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, and Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Simon Keely
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, and Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Mark Morrison
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia,Faculty of Medicine, University of Queensland, Brisbane, Australia,University of Queensland Diamantina Institute, Woolloongabba, Australia,CONTACT Mark Morrison
| | - Gerald J Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia,Translational Research Institute Queensland, Australia,Faculty of Medicine, University of Queensland, Brisbane, Australia,Gerald J Holtmann Princess Alexandra Hospital, Brisbane Department of Gastroenterology and Hepatology & University of Queensland 199 Ipswich Road, Woolloongabba, Queensland, Australia
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7
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Rotondi Aufiero V, Sapone A, Mazzarella G. Diploid Wheats: Are They Less Immunogenic for Non-Celiac Wheat Sensitive Consumers? Cells 2022; 11:cells11152389. [PMID: 35954233 PMCID: PMC9368055 DOI: 10.3390/cells11152389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022] Open
Abstract
Non-celiac wheat sensitivity (NCWS) is a clinical entity induced by the ingestion of gluten that leads to intestinal and/or extraintestinal symptoms, and is diagnosed when celiac disease and wheat allergy have been ruled out. In addition to gluten, other grains’ components, including amylase trypsin inhibitors (ATIs) and fermentable short-chain carbohydrates (FODMAPs), may trigger symptoms in NCWS subjects. Several studies suggest that, compared with tetraploid and hexaploid modern wheats, ancient diploid wheats species could possess a lower immunogenicity for subjects suffering from NCWS. This review aims to discuss available evidence related to the immunological features of diploid wheats compared to common wheats, and at outlining new dietary opportunities for NCWS subjects.
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Affiliation(s)
| | - Anna Sapone
- Center for Celiac Research and Treatment, Massachusetts General Hospital, Boston, MA 02114, USA;
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8
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Non-Celiac Gluten Sensitivity and Protective Role of Dietary Polyphenols. Nutrients 2022; 14:nu14132679. [PMID: 35807860 PMCID: PMC9268201 DOI: 10.3390/nu14132679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/24/2022] [Indexed: 12/11/2022] Open
Abstract
Pathogenetically characterized by the absence of celiac disease and wheat allergy, non-celiac gluten sensitivity (NCGS) is a clinical entity triggered by the consumption of gluten-containing foods that relieved by a gluten-free diet. Since it is very difficult to maintain a complete gluten-free diet, there is a high interest in discovering alternative strategies aimed at reducing gluten concentration or mitigating its toxic effects. Plant-based dietary models are usually rich in bioactive compounds, such as polyphenols, recognized to prevent, delay, or even reverse chronic diseases, including intestinal disorders. However, research on the role of polyphenols in mitigating the toxicity of gluten-containing foods is currently limited. We address the metabolic fate of dietary polyphenols, both as free and bound macromolecule-linked forms, with particular reference to the gastrointestinal compartment, where the concentration of polyphenols can reach high levels. We analyze the potential targets of polyphenols including the gluten peptide bioavailability, the dysfunction of the intestinal epithelial barrier, intestinal immune response, oxidative stress and inflammation, and dysbiosis. Overall, this review provides an updated overview of the effects of polyphenols as possible dietary strategies to counteract the toxic effects of gluten, potentially resulting in the improved quality of life of patients with gluten-related disorders.
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9
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Cárdenas-Torres FI, Cabrera-Chávez F, Figueroa-Salcido OG, Ontiveros N. Non-Celiac Gluten Sensitivity: An Update. ACTA ACUST UNITED AC 2021; 57:medicina57060526. [PMID: 34073654 PMCID: PMC8224613 DOI: 10.3390/medicina57060526] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 12/12/2022]
Abstract
Non-celiac gluten sensitivity (NCGS) is a clinical entity characterized by the absence of celiac disease and wheat allergy in patients that trigger reproducible symptomatic responses to gluten-containing foods consumption. Due to the lack of sensitive and reproducible biomarkers for NCGS diagnosis, placebo-controlled gluten challenges must be carried out for its diagnosis. The gluten challenges can be either double- or single-blind, for research or clinical practice purposes, respectively. For improving our understanding about the magnitude and relevance of NCGS in different populations, epidemiological studies based on self-report have been carried out. However, the gluten challenge-based prevalence of NCGS remains to be estimated. Since NCGS was recently recognized as a clinical entity, more studies are needed to delve into NCGS pathogenesis, for instance, the molecular interactions between the suspected cereal grain components that trigger NCGS, such as fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs) and amylase and trypsin inhibitors, and the immune system remains to be elucidated. Although still under debate, NCGS patients can be susceptible to only one or more than one of the NCGS triggers. The treatment of NCGS involves the dietary restriction of the suspected triggers of the disease, but there is controversial data about the effectiveness of different dietary interventions such as the gluten-free diet and low-FODMAP diet. Certainly, our understanding of NCGS is improving quickly due to the constant availability of new scientific information on this topic. Thus, the aim of the present narrative review is to present an up-to-date overview on NCGS from epidemiology to current therapy.
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Affiliation(s)
- Feliznando Isidro Cárdenas-Torres
- Doctorate Program in Nutrition Science, Faculty of Nutrition Sciences, University of Sinaloa, Culiacán 80019, Mexico; (F.I.C.-T.); (F.C.-C.)
| | - Francisco Cabrera-Chávez
- Doctorate Program in Nutrition Science, Faculty of Nutrition Sciences, University of Sinaloa, Culiacán 80019, Mexico; (F.I.C.-T.); (F.C.-C.)
| | - Oscar Gerardo Figueroa-Salcido
- Postgraduate in Health Sciences, Division of Biological and Health Sciences, University of Sonora, Hermosillo 83000, Mexico
- Correspondence: (O.G.F.-S.); (N.O.)
| | - Noé Ontiveros
- Clinical and Research Laboratory (LACIUS, URS), Department of Chemical, Biological, and Agricultural Sciences (DC-QB), Division of Sciences and Engineering, University of Sonora, Navojoa 85880, Mexico
- Correspondence: (O.G.F.-S.); (N.O.)
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10
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Afzal M, Sielaff M, Curella V, Neerukonda M, El Hassouni K, Schuppan D, Tenzer S, Longin CFH. Characterization of 150 Wheat Cultivars by LC-MS-Based Label-Free Quantitative Proteomics Unravels Possibilities to Design Wheat Better for Baking Quality and Human Health. PLANTS (BASEL, SWITZERLAND) 2021; 10:424. [PMID: 33668233 PMCID: PMC7996164 DOI: 10.3390/plants10030424] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 02/06/2023]
Abstract
Wheat (Triticum aestivum ssp. aestivum) contributes to 20% of the human protein supply, delivers essential amino acids and is of fundamental importance for bread and pasta quality. Wheat proteins are also involved in adverse human reactions like celiac disease (CD), wheat allergy (WA) and non-celiac wheat sensitivity (NCWS). Using liquid chromatography-mass spectrometry (LC-MS)-based label-free quantitative (LFQ) proteomics of aqueous flour extracts, we determined 756 proteins across 150 wheat cultivars grown in three environments. However, only 303 proteins were stably expressed across all environments in at least one cultivar and only 89 proteins thereof across all 150 cultivars. This underlines the large influence of environmental conditions on the expression of many proteins. Wheat cultivars varied largely in their protein profile, shown by high coefficients of variation across different cultivars. Heritability (h2) ranged from 0-1, with 114 proteins having h² > 0.6, including important proteins for baking quality and human health. The expression of these 114 proteins should be amenable to targeted manipulation across the wheat supply chain by varietal choice and breeding for designing healthier wheat with better quality. Further technical development is urgently required to assign functions to identifiable proteins labeled yet uncharacterized in databases and speeding up detection methods to routinely use proteomics in wheat supply chains.
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Affiliation(s)
- Muhammad Afzal
- State Plant Breeding Institute, University of Hohenheim, Fruwirthstr. 21, 70599 Stuttgart, Germany; (M.A.); (K.E.H.)
| | - Malte Sielaff
- Institute for Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (M.S.); (S.T.)
| | - Valentina Curella
- Institute of Translational Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (V.C.); (M.N.); (D.S.)
| | - Manjusha Neerukonda
- Institute of Translational Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (V.C.); (M.N.); (D.S.)
| | - Khaoula El Hassouni
- State Plant Breeding Institute, University of Hohenheim, Fruwirthstr. 21, 70599 Stuttgart, Germany; (M.A.); (K.E.H.)
| | - Detlef Schuppan
- Institute of Translational Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (V.C.); (M.N.); (D.S.)
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Stefan Tenzer
- Institute for Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; (M.S.); (S.T.)
| | - C. Friedrich H. Longin
- State Plant Breeding Institute, University of Hohenheim, Fruwirthstr. 21, 70599 Stuttgart, Germany; (M.A.); (K.E.H.)
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11
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Sergi C, Villanacci V, Carroccio A. Non-celiac wheat sensitivity: rationality and irrationality of a gluten-free diet in individuals affected with non-celiac disease: a review. BMC Gastroenterol 2021; 21:5. [PMID: 33407153 PMCID: PMC7788993 DOI: 10.1186/s12876-020-01568-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 12/03/2020] [Indexed: 02/08/2023] Open
Abstract
Non-celiac gluten or wheat sensitivity (NCWS) is a “clinical entity induced by the ingestion of wheat leading to intestinal and/or extraintestinal symptoms that improve once the wheat-containing foodstuff is removed from the diet, and celiac disease and wheat allergy have been excluded”. This mostly accepted definition raises several points that remain controversial on this condition. In the present review, the authors summarize the most recent advances in the clinic and research on NCWS through an accurate analysis of different studies. We screened PubMed, Medline, Embase, and Scopus using the keywords “non-celiac gluten sensitivity”, “non-celiac wheat sensitivity”, and “diagnosis”. We would like to emphasize two main points, including (A) the controversial clinical and etiological aspects in different trials and experiences with particular attention to the Salerno criteria for the diagnosis of NCWS and (B) the histological aspects. The etiology of NCWS remains controversial, and the relationship with irritable bowel syndrome is obscure. Histologically, the duodenal mucosa may show a variable pattern from unremarkable to a slight increase in the number of T lymphocytes in the superficial epithelium of villi. The endorsement of this disease is based on a positive response to a gluten-free diet for a limited period, followed by the reappearance of symptoms after gluten challenge. The Salerno expert criteria may help to diagnose NCWS accurately. Social media and inaccurate interpretation of websites may jeopardize the diagnostic process if individuals self-label as gluten intolerant.
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Affiliation(s)
- Consolato Sergi
- Department of Laboratory Medicine and Pathology, Stollery Children's Hospital, University of Alberta, 8440 112 St., Edmonton, AB, T6G 2B7, Canada.
| | | | - Antonio Carroccio
- Internal Medicine Unit, "V Cervello Hospital", Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90129, Palermo, Italy
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12
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Castillo-Rodal AI, Furuzawa-Carballeda J, Peláez-Luna M, Castro-Gómez J, López-Vidal Y, Uscanga L. More fuel to the fire: some patients with non-celiac self-reported wheat sensitivity exhibit adaptive immunological responses in duodenal mucosa. BMC Gastroenterol 2020; 20:414. [PMID: 33297984 PMCID: PMC7726874 DOI: 10.1186/s12876-020-01564-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/30/2020] [Indexed: 02/08/2023] Open
Abstract
Background In contrast to the well-characterized Celiac Disease (CD), the clinical scenarios encompassed by the non-celiac self-reported wheat sensitivity (NCSRWS) might be related to different antigens that trigger distinct immune-inflammatory reactions. Although an increased number of intestinal intraepithelial lymphocytes is observed at the inception of both diseases, the subsequent immunopathogenic pathways seem to be different. We aimed to describe the cytokine profile observed in the duodenal mucosa of patients with NCSRWS. Methods In a blind, cross-sectional study, we included duodenal biopsies from 15 consecutive untreated patients with active CD, 9 individuals with NCSRWS and 10 subjects with dyspepsia without CD and food intolerances. Immunohistochemistry and flow-cytometry were used to determine the presence of pro-inflammatory cytokine expressing monocytes and monocyte-derived dendritic cells involved in innate immune activation, cytokine-driven polarization and maintenance of Th1 and Th17/Th 22, and anti-inflammatory/profibrogenic cytokines. Results The percentage of cells expressing all tested cytokines in the lamina propria and the epithelium was higher in CD patients than in the control group. Cytokines that induce and maintain Th1 and Th17 polarization were higher in CD than in NCSRWS and controls, also were higher in NCSRWS compared to controls. Similar differences were detected in the expression of IL-4 and TGF-1, while IL-10-expressing cells were lower in NCSRWS patients than in controls and CD subjects. Conclusions NCSRWS patients exhibit components of both, innate and adaptive immune mechanisms but to a lesser extent compared to CD.
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Affiliation(s)
- Antonia Isabel Castillo-Rodal
- Department of Microbiology and Parasitology, Facultad de Medicina, Universidad Nacional Autónoma de México, Alcaldía de Coyoacán, Mexico City, Mexico
| | - Janette Furuzawa-Carballeda
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Alcaldía de Tlalpan, 14000, Mexico City, Mexico
| | - Mario Peláez-Luna
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Alcaldía de Tlalpan, 14000, Mexico City, Mexico
| | - José Castro-Gómez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Alcaldía de Tlalpan, 14000, Mexico City, Mexico
| | - Yolanda López-Vidal
- Department of Microbiology and Parasitology, Facultad de Medicina, Universidad Nacional Autónoma de México, Alcaldía de Coyoacán, Mexico City, Mexico
| | - Luis Uscanga
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Alcaldía de Tlalpan, 14000, Mexico City, Mexico.
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Abstract
Wheat-based foods have been staple foods since about 10,000 years and constitute a major source of energy, dietary fiber, and micronutrients for the world population. The role of wheat in our diet, however, has recently been scrutinized by pseudoscientific books and media reports promoting the overall impression that wheat consumption makes people sick, stupid, fat, and addicted. Consequently, numerous consumers in Western countries have started to question their dietary habits related to wheat consumption and voluntarily decided to adopt a wheat-free diet without a medical diagnosis of any wheat-related disorder (WRD), such as celiac disease, wheat allergy, or non-celiac gluten sensitivity. The aim of this review is to achieve an objective judgment of the positive aspects of wheat consumption as well as adverse effects for individuals suffering from WRDs. The first part presents wheat constituents and their positive nutritional value, in particular, the consumption of products from whole-grain flours. The second part is focused on WRDs that affect predisposed individuals and can be treated with a gluten-free or -reduced diet. Based on all available scientific knowledge, wheat consumption is safe and healthy for the vast majority of people. There is no scientific evidence to support that the general population would benefit from a wheat-free diet.
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Affiliation(s)
| | | | - Katharina A. Scherf
- Department of Bioactive and Functional Food Chemistry, Institute of Applied Biosciences, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
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Sourdough Fermentation Degrades Wheat Alpha-Amylase/Trypsin Inhibitor (ATI) and Reduces Pro-Inflammatory Activity. Foods 2020; 9:foods9070943. [PMID: 32708800 PMCID: PMC7404469 DOI: 10.3390/foods9070943] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022] Open
Abstract
The ingestion of gluten-containing foods can cause wheat-related disorders in up to 15% of wheat consuming populations. Besides the role of gluten, α-amylase/trypsin inhibitors (ATI) have recently been identified as inducers of an innate immune response via toll-like receptor 4 in celiac disease and non-celiac wheat sensitivity. ATI are involved in plant self-defense against insects and possibly in grain development. Notably, they are largely resistant to gastrointestinal proteases and heat, and their inflammatory activity affects not only the intestine, but also peripheral organs. The aim of this study was to understand the changes of ATI throughout the sourdough and yeast-fermented bread-making processes. ATI tetramers were isolated, fluorescein-labelled, and added to a mini-dough bread-making system. When the pH decreased below 4.0 in sourdough fermentation, the ATI tetramers were degraded due to the activation of aspartic proteases, whilst in yeast fermentation, ATI tetramers remained intact. The amylase inhibitory activity after sourdough fermentation decreased significantly, while the concentration of free thiol groups increased. The glutathione reductase activity of Fructilactobacillus sanfranciscensis did not contribute to the reduction of ATI tetramers. Compared to the unfermented wheat, sourdough fermentation was able to decrease the release of pro-inflammatory cytokines monocyte chemoattractant protein-1 (MCP-1) and tumor necrosis factor alpha (TNF-α) in quantitative ATI extracts added to the human monocytic cell line THP-1. The current data suggest that sourdough fermentation can degrade ATI structure and bioactivity, and point to strategies to improve product development for wheat sensitivity patients.
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15
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Di Stasio L, Picascia S, Auricchio R, Vitale S, Gazza L, Picariello G, Gianfrani C, Mamone G. Comparative Analysis of in vitro Digestibility and Immunogenicity of Gliadin Proteins From Durum and Einkorn Wheat. Front Nutr 2020; 7:56. [PMID: 32671087 PMCID: PMC7326042 DOI: 10.3389/fnut.2020.00056] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 04/08/2020] [Indexed: 12/15/2022] Open
Abstract
Recent studies suggested that gliadin proteins from the ancient diploid einkorn wheat Triticum monococcum retained a reduced number of immunogenic peptides for celiac disease patients because of a high in vitro digestibility with respect to hexaploid common wheat. In this study, we compared the immunological properties of gliadins from two Triticum monococcum cultivars (Hammurabi and Norberto-ID331) with those of a Triticum durum cultivar (Adamello). Gliadins were digested by mimicking the in vitro gastrointestinal digestion process that includes the brush border membrane peptidases. Competitive ELISA, based on R5 monoclonal antibody, showed that gastrointestinal digestion reduced the immunogenicity of Triticum monococcum gliadins; conversely, the immunogenic potential of Triticum durum gliadins remained almost unchanged by the in vitro digestion. The immune stimulatory activity was also evaluated by detecting the IFN-γ production in gliadin-reactive T-cell lines obtained from the small intestinal mucosa of HLA-DQ2+ celiac disease patients. Interestingly, gastrointestinal digestion markedly reduced the capability of Triticum monococcum gliadins (p <0.05) of both cultivars to activate T cells, while it slightly affected the activity of Triticum durum. In conclusion, our results showed that Triticum durum was almost unaffected by the in vitro gastrointestinal digestion, while Triticum monococcum had a marked sensibility to digestion, thus determining a lower toxicity for celiac disease patients.
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Affiliation(s)
- Luigia Di Stasio
- Institute of Food Sciences, National Research Council, Avellino, Italy
| | - Stefania Picascia
- Institute of Biochemistry and Cell Biology, National Research Council, Naples, Italy
| | - Renata Auricchio
- Department of Translational Medical Science, Section of Paediatrics, European Laboratory for the Investigation of Food-Induced Diseases, University "Federico II", Naples, Italy
| | - Serena Vitale
- Institute of Biochemistry and Cell Biology, National Research Council, Naples, Italy
| | - Laura Gazza
- CREA-Research Centre for Engineering and Agro-Food Processing, Rome, Italy
| | | | - Carmen Gianfrani
- Institute of Biochemistry and Cell Biology, National Research Council, Naples, Italy
| | - Gianfranco Mamone
- Institute of Food Sciences, National Research Council, Avellino, Italy
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16
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Exit Gluten-Free and Enter Low FODMAPs: A Novel Dietary Strategy to Reduce Gastrointestinal Symptoms in Athletes. Sports Med 2020; 49:87-97. [PMID: 30671907 PMCID: PMC6445805 DOI: 10.1007/s40279-018-01034-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Exercise-associated physiological disturbances alter gastrointestinal function and integrity. These alterations may increase susceptibility to dietary triggers, namely gluten and a family of short-chain carbohydrates known as FODMAPs (fermentable oligo-, di-, monosaccharides and polyols). A recent surge in the popularity of gluten-free diets (GFDs) among athletes without celiac disease has been exacerbated by unsubstantiated commercial health claims and high-profile athletes citing this diet to be the secret to their success. Up to 41% of athletes at least partially adhere to a GFD diet, with the belief that gluten avoidance improves exercise performance and parameters influencing performance, particularly gastrointestinal symptoms (GIS). In contrast to these beliefs, seminal work investigating the effects of a GFD in athletes without celiac disease has demonstrated no beneficial effect of a GFD versus a gluten-containing diet on performance, gastrointestinal health, inflammation, or perceptual wellbeing. Interestingly, the subsequent reduction in FODMAPs concurrent with the elimination of gluten-containing grains may actually be the factors affecting GIS improvement, not gluten. Pre-existent in the gastrointestinal tract or ingested during exercise, the osmotic and gas-producing effects of variably absorbed FODMAPs may trigger or increase the magnitude of exercise-associated GIS. Research using FODMAP reduction to address gastrointestinal issues in clinically healthy athletes is emerging as a promising strategy to reduce exercise-associated GIS. Applied research and practitioners merging clinical and sports nutrition methods will be essential for the effective use of a low FODMAP approach to tackle the multifactorial nature of gastrointestinal disturbances in athletes.
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17
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Efthymakis K, Clemente E, Marchioni M, Di Nicola M, Neri M, Sallese M. An Exploratory Gene Expression Study of the Intestinal Mucosa of Patients with Non-Celiac Wheat Sensitivity. Int J Mol Sci 2020; 21:ijms21061969. [PMID: 32183058 PMCID: PMC7139384 DOI: 10.3390/ijms21061969] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/06/2020] [Accepted: 03/11/2020] [Indexed: 12/12/2022] Open
Abstract
Non-celiac wheat sensitivity (NCWS) is a recently recognized syndrome triggered by a gluten-containing diet. The pathophysiological mechanisms engaged in NCWS are poorly understood and, in the absence of laboratory markers, the diagnosis relies only on a double-blind protocol of symptoms evaluation during a gluten challenge. We aimed to shed light on the molecular mechanisms governing this disorder and identify biomarkers helpful to the diagnosis. By a genome-wide transcriptomic analysis, we investigated gene expression profiles of the intestinal mucosa of 12 NCWS patients, as well as 7 controls. We identified 300 RNA transcripts whose expression differed between NCWS patients and controls. Only 37% of these transcripts were protein-coding RNA, whereas the remaining were non-coding RNA. Principal component analysis (PCA) and receiver operating characteristic curves showed that these microarray data are potentially useful to set apart NCWS from controls. Literature and network analyses indicated a possible implication/dysregulation of innate immune response, hedgehog pathway, and circadian rhythm in NCWS. This exploratory study indicates that NCWS can be genetically defined and gene expression profiling might be a suitable tool to support the diagnosis. The dysregulated genes suggest that NCWS may result from a deranged immune response. Furthermore, non-coding RNA might play an important role in the pathogenesis of NCWS.
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Affiliation(s)
- Konstantinos Efthymakis
- Department of Medicine and Ageing Sciences, ‘G. d’Annunzio’ University of Chieti–Pescara, 66100 Chieti, Italy;
- Center for Advanced Studies and Technology (CAST), ‘G. d’Annunzio’ University of Chieti-Pescara, 66100 Chieti, Italy;
| | - Emanuela Clemente
- Center for Advanced Studies and Technology (CAST), ‘G. d’Annunzio’ University of Chieti-Pescara, 66100 Chieti, Italy;
- Department of Medical, Oral and Biotechnological Sciences, ‘G. d’Annunzio’ University of Chieti–Pescara, 66100 Chieti, Italy; (M.M.); (M.D.N.)
| | - Michele Marchioni
- Department of Medical, Oral and Biotechnological Sciences, ‘G. d’Annunzio’ University of Chieti–Pescara, 66100 Chieti, Italy; (M.M.); (M.D.N.)
| | - Marta Di Nicola
- Department of Medical, Oral and Biotechnological Sciences, ‘G. d’Annunzio’ University of Chieti–Pescara, 66100 Chieti, Italy; (M.M.); (M.D.N.)
| | - Matteo Neri
- Department of Medicine and Ageing Sciences, ‘G. d’Annunzio’ University of Chieti–Pescara, 66100 Chieti, Italy;
- Center for Advanced Studies and Technology (CAST), ‘G. d’Annunzio’ University of Chieti-Pescara, 66100 Chieti, Italy;
- Correspondence: (M.N.); (M.S.)
| | - Michele Sallese
- Center for Advanced Studies and Technology (CAST), ‘G. d’Annunzio’ University of Chieti-Pescara, 66100 Chieti, Italy;
- Department of Medical, Oral and Biotechnological Sciences, ‘G. d’Annunzio’ University of Chieti–Pescara, 66100 Chieti, Italy; (M.M.); (M.D.N.)
- Correspondence: (M.N.); (M.S.)
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18
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Differential Physiological Responses Elicited by Ancient and Heritage Wheat Cultivars Compared to Modern Ones. Nutrients 2019; 11:nu11122879. [PMID: 31779167 PMCID: PMC6950659 DOI: 10.3390/nu11122879] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 11/22/2019] [Indexed: 02/07/2023] Open
Abstract
Although ancient, heritage, and modern wheat varieties appear rather similar from a nutritional point of view, having a similar gluten content and a comparable toxicity linked to their undigested gluten peptide, whenever the role of ancient end heritage wheat grains has been investigated in animal studies or in clinical trials, more anti-inflammatory effects have been associated with the older wheat varieties. This review provides a critical overview of existing data on the differential physiological responses that could be elicited in the human body by ancient and heritage grains compared to modern ones. The methodology used was that of analyzing the results of relevant studies conducted from 2010 through PubMed search, by using as keywords “ancient or heritage wheat”, “immune wheat” (protein or peptides), and immune gluten (protein or peptides). Our conclusion is that, even if we do not know exactly which molecular mechanisms are involved, ancient and heritage wheat varieties have different anti-inflammatory and antioxidant proprieties with respect to modern cultivars. It is, therefore, reasonable to assume that the health proprieties attributed to older cultivars could be related to wheat components which have positive roles in the modulation of intestinal inflammation and/or permeability.
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19
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Hoffmanová I, Sánchez D, Szczepanková A, Tlaskalová-Hogenová H. The Pros and Cons of Using Oat in a Gluten-Free Diet for Celiac Patients. Nutrients 2019; 11:nu11102345. [PMID: 31581722 PMCID: PMC6835965 DOI: 10.3390/nu11102345] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/12/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023] Open
Abstract
A therapeutic gluten-free diet often has nutritional limitations. Nutritional qualities such as high protein content, the presence of biologically active and beneficial substances (fiber, beta-glucans, polyunsaturated fatty acids, essential amino acids, antioxidants, vitamins, and minerals), and tolerance by the majority of celiac patients make oat popular for use in gluten-free diet. The health risk of long-time consumption of oat by celiac patients is a matter of debate. The introduction of oat into the diet is only recommended for celiac patients in remission. Furthermore, not every variety of oat is also appropriate for a gluten-free diet. The risk of sensitization and an adverse immunologically mediated reaction is a real threat in some celiac patients. Several unsolved issues still exist which include the following: (1) determination of the susceptibility markers for the subgroup of celiac patients who are at risk because they do not tolerate dietary oat, (2) identification of suitable varieties of oat and estimating the safe dose of oat for the diet, and (3) optimization of methods for detecting the gliadin contamination in raw oat used in a gluten-free diet.
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Affiliation(s)
- Iva Hoffmanová
- 2nd Department of Internal Medicine, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Ruská 87, 10000 Prague, Czech Republic.
| | - Daniel Sánchez
- Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Vídeňská 1083, 14220 Prague, Czech Republic.
| | - Adéla Szczepanková
- Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Vídeňská 1083, 14220 Prague, Czech Republic.
- First Faculty of Medicine, Charles University, Kateřinská 1660/32, 121 08 Prague, Czech Republic.
| | - Helena Tlaskalová-Hogenová
- Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Vídeňská 1083, 14220 Prague, Czech Republic.
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Rustgi S, Shewry P, Brouns F, Deleu LJ, Delcour JA. Wheat Seed Proteins: Factors Influencing Their Content, Composition, and Technological Properties, and Strategies to Reduce Adverse Reactions. Compr Rev Food Sci Food Saf 2019; 18:1751-1769. [PMID: 33336954 DOI: 10.1111/1541-4337.12493] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/16/2019] [Accepted: 07/10/2019] [Indexed: 02/06/2023]
Abstract
Wheat is the primary source of nutrition for many, especially those living in developing countries, and wheat proteins are among the most widely consumed dietary proteins in the world. However, concerns about disorders related to the consumption of wheat and/or wheat gluten proteins have increased sharply in the last 20 years. This review focuses on wheat gluten proteins and amylase trypsin inhibitors, which are considered to be responsible for eliciting most of the intestinal and extraintestinal symptoms experienced by susceptible individuals. Although several approaches have been proposed to reduce the exposure to gluten or immunogenic peptides resulting from its digestion, none have proven sufficiently effective for general use in coeliac-safe diets. Potential approaches to manipulate the content, composition, and technological properties of wheat proteins are therefore discussed, as well as the effects of using gluten isolates in various food systems. Finally, some aspects of the use of gluten-free commodities are discussed.
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Affiliation(s)
- Sachin Rustgi
- Dept. of Plant and Environmental Sciences, School of Health Research, Clemson Univ. Pee Dee Research and Education Centre, Florence, SC, U.S.A.,Dept. of Crop and Soil Sciences, Washington State Univ., Pullman, WA, U.S.A
| | - Peter Shewry
- Rothamsted Research, Harpenden, Hertfordshire, U.K
| | - Fred Brouns
- Dept. of Human Biology, School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht Univ., Universiteitssingel 50, 6200, MD, Maastricht, the Netherlands
| | - Lomme J Deleu
- Laboratory of Food Chemistry and Biochemistry, Leuven Food Science and Nutrition Research Centre (LFoRCe), KU Leuven, Kasteelpark Arenberg 20, B-3001, Leuven, Belgium
| | - Jan A Delcour
- Laboratory of Food Chemistry and Biochemistry, Leuven Food Science and Nutrition Research Centre (LFoRCe), KU Leuven, Kasteelpark Arenberg 20, B-3001, Leuven, Belgium
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21
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Skodje GI, Minelle IH, Rolfsen KL, Iacovou M, Lundin KE, Veierød MB, Henriksen C. Dietary and symptom assessment in adults with self-reported non-coeliac gluten sensitivity. Clin Nutr ESPEN 2019; 31:88-94. [DOI: 10.1016/j.clnesp.2019.02.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/20/2019] [Indexed: 01/26/2023]
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Neumann J, Ziegler K, Gelléri M, Fröhlich-Nowoisky J, Liu F, Bellinghausen I, Schuppan D, Birk U, Pöschl U, Cremer C, Lucas K. Nanoscale distribution of TLR4 on primary human macrophages stimulated with LPS and ATI. NANOSCALE 2019; 11:9769-9779. [PMID: 31066732 DOI: 10.1039/c9nr00943d] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Toll-like receptor 4 (TLR4) plays a crucial role in the recognition of invading pathogens. Upon activation by lipopolysaccharides (LPS), TLR4 is recruited into specific membrane domains and dimerizes. In addition to LPS, TLR4 can be stimulated by wheat amylase-trypsin inhibitors (ATI). ATI are proteins associated with gluten containing grains, whose ingestion promotes intestinal and extraintestinal inflammation. However, the effect of ATI vs. LPS on the membrane distribution of TLR4 at the nanoscale has not been analyzed. In this study, we investigated the effect of LPS and ATI stimulation on the membrane distribution of TLR4 in primary human macrophages using single molecule localization microscopy (SMLM). We found that in unstimulated macrophages the majority of TLR4 molecules are located in clusters, but with donor-dependent variations from ∼51% to ∼75%. Depending on pre-clustering, we found pronounced variations in the fraction of clustered molecules and density of clusters on the membrane upon LPS and ATI stimulation. Although clustering differed greatly among the human donors, we found an almost constant cluster diameter of ∼44 nm for all donors, independent of treatment. Together, our results show donor-dependent but comparable effects between ATI and LPS stimulation on the membrane distribution of TLR4. This may indicate a general mechanism of TLR4 activation in primary human macrophages. Furthermore, our methodology visualizes TLR4 receptor clustering and underlines its functional role as a signaling platform.
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Affiliation(s)
- Jan Neumann
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Hahn-Meitner-Weg 1, 55128 Mainz, Germany.
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Abstract
PURPOSE OF REVIEW There has been significant interest in gluten over the last decade, with an increase in interest of gluten-related disorders outside coeliac disease. Particularly, there has been a focus on the role of gluten in noncoeliac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS). There is significant overlap between both of these conditions, with the aim of this review to explore their complex relationship. RECENT FINDINGS Gluten has been demonstrated to generate symptoms in individuals with NCGS. However, there appears to be an increasing role for gluten in symptom generation in patients with IBS also. Other components of wheat, other than gluten, are now also thought to be contributing factors in symptom generation. SUMMARY There appears to be significant overlap between IBS and NCGS. It is likely that a subset of patients presenting with IBS actually have NCGS. In addition, it is likely that individuals with IBS may also have symptoms triggered by gluten. With the pathophysiology of both conditions not fully understood, as well as increasing knowledge of wheat components in symptom generation, further research is required to help distinguish between both.
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Figueroa-Salcido OG, Ontiveros N, Cabrera-Chavez F. Gluten Vehicle and Placebo for Non-Celiac Gluten Sensitivity Assessment. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E117. [PMID: 31035487 PMCID: PMC6572297 DOI: 10.3390/medicina55050117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/20/2019] [Accepted: 04/23/2019] [Indexed: 12/13/2022]
Abstract
Non-celiac gluten sensitivity (NCGS) is a syndrome characterized by gastrointestinal and extraintestinal manifestations triggered after gluten ingestion in the absence of celiac disease and wheat allergy. Because of the lack of biomarkers for NCGS diagnosis, the cornerstone for its assessment is a single- or double-blind placebo-controlled (DBPC) gluten challenge. However, there are some non-standardized points in the diagnostic approach proposed by the experts. This complicate comparisons among the results published by different research groups. The gluten vehicle and placebo must be indistinguishable from each other, which entails sensory and technological evaluations of the designed gluten vehicle and placebo products. At the moment, there is no standardized method for the preparation of the gluten vehicle and placebo for carrying out DBPC gluten challenges for NCGS assessment. This review focuses on the challenges that researchers have to face, either for the development of an accepted gluten vehicle and placebo or for identifying NCGS cases on the basis of DBPC gluten challenges.
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Affiliation(s)
- Oscar Gerardo Figueroa-Salcido
- Nutrition Sciences Academic Unit, Autonomous University of Sinaloa, Cedros y Calle Sauces S/N, Fraccionamiento Los Fresnos, Culiacán 80019, Sinaloa, Mexico.
| | - Noé Ontiveros
- Division of Sciences and Engineering, Department of Chemical, Biological, and Agricultural Sciences (DC-QB), University of Sonora, Navojoa 85880, Sonora, Mexico.
| | - Francisco Cabrera-Chavez
- Nutrition Sciences Academic Unit, Autonomous University of Sinaloa, Cedros y Calle Sauces S/N, Fraccionamiento Los Fresnos, Culiacán 80019, Sinaloa, Mexico.
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25
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Bose U, Byrne K, Howitt CA, Colgrave ML. Targeted proteomics to monitor the extraction efficiency and levels of barley α-amylase trypsin inhibitors that are implicated in non-coeliac gluten sensitivity. J Chromatogr A 2019; 1600:55-64. [PMID: 31036362 DOI: 10.1016/j.chroma.2019.04.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/10/2019] [Accepted: 04/16/2019] [Indexed: 12/19/2022]
Abstract
Plant defense protein α-amylase trypsin inhibitors (ATIs) have been proposed as one of the triggers of non-coeliac gluten sensitivity, however there have been no focused studies on their optimal extraction and quantitation from cereal grains. The efficiency of extraction is of utmost interest for the downstream detection and characterisation. In the present study, three extraction buffers and two modified protocols were investigated using LC-MRM-MS in order to examine their ability to efficiently and repeatably extract ATIs from selected barley cultivars. Initially, three extraction buffers IPA/DTT, urea and Tris-HCl were used to extract ATIs from two selected barley cultivars, Commander and Hindmarsh. The results obtained from the preliminary study showed that IPA/DTT and urea-based buffer extraction could yield ∼70% and ∼45% more ATIs, respectively than a buffer based on Tris-HCl extraction, with all methods showing high repeatability (CV < 15%). A multi-step protocol, employing IPA/DTT and urea improved the extraction efficiency in comparison to the single buffer extraction protocols (p<0.0001). When solutions from parallel extractions using IPA/DTT and urea were combined, the results were comparable (p = 0.99) with a sequential multi-step IPA/DTT-urea protocol. However, the repeatability of the combined process was compromised, as discerned by greater variation (CV>30%). The optimised sequential two-step extraction protocol was successfully used to extract and quantify ATIs from 12 barley cultivars. LC-MS analysis revealed that cv Yagan and cv Scope contain the higher levels (∼143% relative to the average barley ATI content), whereas cultivars Fleet (61%), Baudin (77%) and Commander (79%) contained the lowest levels. The libraries of ATIs identified and the quantitative methods described here provide a foundation for the future application of MS-based quantitative methodologies to detect and quantify ATIs in barley varieties and in food products.
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Affiliation(s)
- Utpal Bose
- CSIRO Agriculture and Food, 306 Carmody Rd, St Lucia, QLD, 4067, Australia.
| | - Keren Byrne
- CSIRO Agriculture and Food, 306 Carmody Rd, St Lucia, QLD, 4067, Australia.
| | - Crispin A Howitt
- CSIRO Agriculture and Food, GPO Box 1700, Canberra, ACT, 2601, Australia.
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26
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Zhang QL, Zhang GL, Xiong Y, Li HW, Guo J, Wang F, Deng XY, Chen JY, Wang YJ, Lin LB. Genome-wide gene expression analysis reveals novel insights into the response to nitrite stress in gills of Branchiostoma belcheri. CHEMOSPHERE 2019; 218:609-615. [PMID: 30502699 DOI: 10.1016/j.chemosphere.2018.11.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/23/2018] [Accepted: 11/24/2018] [Indexed: 06/09/2023]
Abstract
Amphioxus has been widely used as a model for the comparative immunology of vertebrates. Studies have reported that gene expression changes in the amphioxus gill in response to biotic stress, such as microbial and their mimic challenge, but little is known about how gene expression is affected by abiotic stress in the marine environment, such as nitrite. A lack of information regarding gene expression response to abiotic stress hinders a comprehensive understanding of gill defense response in amphioxus. Here, RNA sequencing was used to carry out gene expression profiling analyses of Branchiostoma belcheri gills under nitrite stress. Six libraries were created for the control and treatment groups, including three biological replicates. In total, 2416 differently expressed genes (DEGs) were detected in response to nitrite stress, of which 1522 DEGs were up-regulated in the treatment group in comparison to the control, while the remaining 894 DEGs were down-regulated genes. Functional enrichment revealed that these DEGs are primarily involved in disease, innate immunity, xenobiotic biodegradation and metabolism, and biomolecular processes and apoptosis. We screened 11 key nitrite-responsive DEGs to detect their expression responses to nitrite stress at different time points, and validate the sequencing data using real time quantitative PCR. The results indicated that the expression of gene encoding CYP3A, POD, CASPR1, GST, MAO, DDH, and XDH/XO were induced, while those encoding MRC, GT, DNASE1L, and RIPK5 were reduced, to participate in the anti-nitrite response. This study provides a useful resource for research of molecular toxicology in amphioxus under environmental stress.
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Affiliation(s)
- Qi-Lin Zhang
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500 China.
| | - Guan-Ling Zhang
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500 China
| | - Yan Xiong
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500 China
| | - Hong-Wei Li
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500 China
| | - Jun Guo
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500 China
| | - Feng Wang
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500 China
| | - Xian-Yu Deng
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500 China
| | - Jun-Yuan Chen
- LPS, Nanjing Institute of Geology and Paleontology, Chinese Academy of Sciences, Nanjing 210008 China; State Key Laboratory of Pharmaceutical Biotechnology, School of Life Science, Nanjing University, Nanjing, 210023 China
| | - Yu-Jun Wang
- Guangxi Key Laboratory of Beibu Gulf Marine Biodiversity Conservation, Ocean College, Qinzhou University, Qinzhou 535011 China.
| | - Lian-Bing Lin
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500 China.
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Duodenal and Rectal Eosinophilia Are New Biomarkers of Nonceliac Gluten Sensitivity. Clin Gastroenterol Hepatol 2019; 17:613-615. [PMID: 30502506 DOI: 10.1016/j.cgh.2018.11.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/18/2018] [Accepted: 11/24/2018] [Indexed: 02/07/2023]
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Ziegler K, Neumann J, Liu F, Fröhlich-Nowoisky J, Cremer C, Saloga J, Reinmuth-Selzle K, Pöschl U, Schuppan D, Bellinghausen I, Lucas K. Nitration of Wheat Amylase Trypsin Inhibitors Increases Their Innate and Adaptive Immunostimulatory Potential in vitro. Front Immunol 2019; 9:3174. [PMID: 30740114 PMCID: PMC6357940 DOI: 10.3389/fimmu.2018.03174] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/24/2018] [Indexed: 01/22/2023] Open
Abstract
Amylase trypsin inhibitors (ATI) can be found in all gluten containing cereals and are, therefore, ingredient of basic foods like bread or pasta. In the gut ATI can mediate innate immunity via activation of the Toll-like receptor 4 (TLR4) on immune cells residing in the lamina propria, promoting intestinal, as well as extra-intestinal, inflammation. Inflammatory conditions can induce formation of peroxynitrite (ONOO-) and, thereby, endogenous protein nitration in the body. Moreover, air pollutants like ozone (O3) and nitrogen dioxide (NO2) can cause exogenous protein nitration in the environment. Both reaction pathways may lead to the nitration of ATI. To investigate if and how nitration modulates the immunostimulatory properties of ATI, they were chemically modified by three different methods simulating endogenous and exogenous protein nitration and tested in vitro. Here we show that ATI nitration was achieved by all three methods and lead to increased immune reactions. We found that ATI nitrated by tetranitromethane (TNM) or ONOO- lead to a significantly enhanced TLR4 activation. Furthermore, in human primary immune cells, TNM nitrated ATI induced a significantly higher T cell proliferation and release of Th1 and Th2 cytokines compared to unmodified ATI. Our findings implicate a causative chain between nitration, enhanced TLR4 stimulation, and adaptive immune responses, providing major implications for public health, as nitrated ATI may strongly promote inhalative wheat allergies (baker's asthma), non-celiac wheat sensitivity (NCWS), other allergies, and autoimmune diseases. This underlines the importance of future work analyzing the relationship between endo- and exogenous protein nitration, and the rise in incidence of ATI-related and other food hypersensitivities.
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Affiliation(s)
- Kira Ziegler
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
| | - Jan Neumann
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany.,Institute of Molecular Biology, Mainz, Germany
| | - Fobang Liu
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
| | | | - Christoph Cremer
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany.,Institute of Molecular Biology, Mainz, Germany
| | - Joachim Saloga
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | | | - Ulrich Pöschl
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Iris Bellinghausen
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Kurt Lucas
- Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany
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29
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Sánchez D, Štěpánová Honzová S, Hospodková M, Hoffmanová I, Hábová V, Halada P, Tlaskalová-Hogenová H, Tučková L. Occurrence of serum antibodies against wheat alpha-amylase inhibitor 0.19 in celiac disease. Physiol Res 2018; 67:613-622. [PMID: 29750882 DOI: 10.33549/physiolres.933876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The alcohol-soluble fraction of wheat gluten (gliadins) induces in genetically susceptible individuals immunologically mediated celiac disease (CLD). However, gliadins and related cereal proteins are not unique foodstuff targets of CLD patients´ immune system. Non-gluten wheat alpha-amylase inhibitor 0.19 (AAI 0.19) has been found to be capable of activating human monocyte-derived dendritic cells and inducing pro-inflammatory status in intestinal mucosa of patients with celiac disease (CLD). The possible contribution of this reactivity in incomplete remission of CLD patients on a gluten-free diet (GFD) is matter of contention. In an attempt to characterize the antigenicity of AAI 0.19 in patients with active CLD, patients on a GFD and healthy controls we developed ELISA employing wheat recombinant AAI 0.19. Using this test we revealed a significant (P<0.001) elevation of IgA anti-AAI 0.19 antibodies (Ab) in patients with active CLD (12 out of 30 patients were seropositive) but also in CLD patients on a GFD (15/46), in contrast to healthy controls (2/59). Anti-AAI 0.19 IgG Ab levels were increased (P<0.001) only in patients with active CLD (14/30) in contrast to the controls. Interestingly, the levels of anti-AAI 0.19 IgG Ab were decreased in CLD patients on a GFD (P<0.001, 1/46) compared to the controls (1/59). Notably, 20 out of 30 patients with active CLD were positive either for IgA or for IgG anti-AAI 0.19 Ab. Thus, the majority of CLD patients developed a robust IgA and IgG Ab response against AAI 0.19. These findings may contribute to the broadening of the knowledge about CLD pathogenesis.
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Affiliation(s)
- D Sánchez
- Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic.
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30
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Rotondi Aufiero V, Fasano A, Mazzarella G. Non-Celiac Gluten Sensitivity: How Its Gut Immune Activation and Potential Dietary Management Differ from Celiac Disease. Mol Nutr Food Res 2018; 62:e1700854. [PMID: 29578652 DOI: 10.1002/mnfr.201700854] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 03/07/2018] [Indexed: 12/13/2022]
Abstract
Non-celiac gluten sensitivity (NCGS) is a clinical entity triggered by the ingestion of gluten-containing grains leading to intestinal and/or extraintestinal symptoms that resolve once the gluten-containing foodstuff is eliminated from the diet, and it is diagnosed when celiac disease (CD) and wheat allergy (WA) have been ruled out. The limited knowledge about the pathophysiology of NCGS and the lack of validated biomarkers are still major limitations for clinical studies, making it difficult to differentiate NCGS from other gluten-related disorders (GRD). In the absence of clear-cut diagnostic criteria, NCGS is still mainly a diagnosis of exclusion. Several studies suggest that NCGS is an immune-mediated disease that likely activates an innate immune response. Moreover, it has recently been hypothesized that in addition to gluten, other components of wheat may be responsible for the symptoms observed in individuals without CD. This review aims at discussing available evidence related to the histological and immunological features in the gut mucosa of patients with NCGS and at outlining new dietary opportunities for these patients.
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Affiliation(s)
- Vera Rotondi Aufiero
- Immuno-Morphology Lab, Institute of Food Sciences, National Council Research, 83100, Avellino, Italy
| | - Alessio Fasano
- Mucosal Immunology and Biology Research Center and Center for Celiac Research and Treatment, MassGeneral Hospital for Children-Harvard Medical School, Boston, MA, 02114-4404, USA
| | - Giuseppe Mazzarella
- Immuno-Morphology Lab, Institute of Food Sciences, National Council Research, 83100, Avellino, Italy
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31
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Dietary wheat amylase trypsin inhibitors exacerbate murine allergic airway inflammation. Eur J Nutr 2018; 58:1507-1514. [PMID: 29600329 DOI: 10.1007/s00394-018-1681-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/27/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Wheat amylase trypsin inhibitors (ATI) are dietary non-gluten proteins that activate the toll-like receptor 4 on myeloid cells, promoting intestinal inflammation. AIM OF THE STUDY We investigated the effects of dietary ATI on experimental allergic airway inflammation. METHODS Mice on a gluten and ATI-free diet (GAFD), sensitized with PBS or ovalbumin (OVA) and challenged with OVA, were compared to mice on a commercial standard chow, a gluten diet naturally containing ~ 0.75% of protein as ATI (G+AD), a gluten diet containing ~ 0.19% of protein as ATI (G-AD) and a GAFD with 1% of protein as ATI (AD). Airway hyperreactivity (AHR), inflammation in bronchoalveolar lavage (BAL) and pulmonary tissue sections were analyzed. Allergic sensitization was assessed ex vivo via proliferation of OVA-stimulated splenocytes. RESULTS Mice on a GAFD sensitized with PBS did not develop AHR after local provocation with methacholine. Mice on a GAFD or on a G-AD and sensitized with OVA developed milder AHR compared to mice fed a G+AD or an AD. The increased AHR was paralleled by increased BAL eosinophils, IL-5 and IL-13 production, and an enhanced ex vivo splenocyte activation in the ATI-fed groups. CONCLUSIONS Dietary ATI enhance allergic airway inflammation in OVA-challenged mice, while an ATI-free or ATI-reduced diet has a protective effect on AHR. Nutritional wheat ATI, activators of intestinal myeloid cells, may be clinically relevant adjuvants to allergic airway inflammation.
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Bellinghausen I, Weigmann B, Zevallos V, Maxeiner J, Reißig S, Waisman A, Schuppan D, Saloga J. Wheat amylase-trypsin inhibitors exacerbate intestinal and airway allergic immune responses in humanized mice. J Allergy Clin Immunol 2018; 143:201-212.e4. [PMID: 29574077 DOI: 10.1016/j.jaci.2018.02.041] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 01/26/2018] [Accepted: 02/05/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Amylase-trypsin inhibitors (ATIs) in wheat and related cereals are potent activators of myeloid innate immune cells via engagement of TLR4. Furthermore, ATIs have been shown to serve as adjuvants in experimental intestinal inflammatory diseases. OBJECTIVE The aim of this study was to analyze whether ATIs are also modifiers of allergic inflammation. METHODS Therefore, CD4+ T cells from donors sensitized to grass or birch pollen were stimulated with autologous allergen-pulsed dendritic cells in the presence or absence of ATIs or the control storage protein zein from corn. To analyze allergen-induced gut and lung inflammation, immunodeficient mice were engrafted with PBMCs from these allergic donors plus the respective allergen, and fed with selected diets. Three weeks later, inflammation was induced by rectal or intranasal allergen challenge and monitored by mini endoscopy or airway hyperreactivity, respectively. RESULTS Allergen-specific T-cell proliferation and cytokine production was significantly exacerbated by ATIs and not by zein. In vivo, allergen-specific human IgE level was strongly elevated in sera of mice receiving an ATI-containing diet compared with mice that were fed gluten-free and thus ATI-free diet. Importantly, allergen-induced IgE-dependent colitis and airway hyperreactivity were also enhanced in ATI-fed mice. Gut inflammation was further increased in mice receiving an additional ATI injection and even detectable in the absence of the aeroallergen, whereas zein had no such effect. Injection of anti-human TLR4 mAbs or the anti-human IgE mAb omalizumab completely abolished ATI-induced allergic inflammation. CONCLUSIONS These results underline that wheat ATIs are important nutritional activators and adjuvants of allergy, which might be exploited for nutritional therapeutic strategies.
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Affiliation(s)
- Iris Bellinghausen
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany.
| | - Benno Weigmann
- Department of Internal Medicine I, University Hospital Erlangen, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Victor Zevallos
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Joachim Maxeiner
- Asthma Core Facility, Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Sonja Reißig
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Institute for Molecular Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Ari Waisman
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Institute for Molecular Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Detlef Schuppan
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Joachim Saloga
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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33
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Reig-Otero Y, Mañes J, Manyes L. Amylase-Trypsin Inhibitors in Wheat and Other Cereals as Potential Activators of the Effects of Nonceliac Gluten Sensitivity. J Med Food 2018; 21:207-214. [PMID: 29315017 DOI: 10.1089/jmf.2017.0018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Nonceliac gluten sensitivity (NCGS) is a gluten-related gastrointestinal disorder distinct from celiac disease (CD) and gluten allergy that is not easy to diagnose due to the lack of biomarkers. It is characterized by intestinal symptoms and extraintestinal manifestations with the consumption of gluten-containing foods. In contrast to CD, NCGS patients do not present a genetic predisposition or intestinal villi atrophy. Recent studies question the proinflammatory triggering activity of α-gliadin fraction contained in wheat, since it has been demonstrated that the amylase-trypsin inhibitors (ATIs) exert a strong activating effect on the innate immune response. We aimed to analyze the role of ATIs in the activation of innate immunity and in the development of the symptoms characteristic of NCGS. A systematic literature search was made using databases such as MEDLINE, SciELO, Science Direct, and Scopus, with focus on key words such as "amylase-trypsin inhibitors," "wheat," "gluten," and "celiac." Many studies are available on the structure, inhibition mechanism, and immune system effects of ATIs, mainly focused on IgE-mediated reactions. Recently, with the increase of NCGS interest, has increased the literature on the capacity of ATIs contained in wheat to activate the innate immune system. Literature published to date questions the relationship between activation of the innate immune system and gluten in NCGS. ATIs may have acted as interfering contaminant of gluten and appear as potential activator of innate immunity in NCGS patients. In view of their potential impact, more interventional studies are needed to demonstrate the proinflammatory effect of ATIs.
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Affiliation(s)
- Yolanda Reig-Otero
- Laboratory of Food Chemistry and Toxicology, Faculty of Pharmacy, University of Valencia, Valencia, Spain
| | - Jordi Mañes
- Laboratory of Food Chemistry and Toxicology, Faculty of Pharmacy, University of Valencia, Valencia, Spain
| | - Lara Manyes
- Laboratory of Food Chemistry and Toxicology, Faculty of Pharmacy, University of Valencia, Valencia, Spain
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T Helper Lymphocyte and Mast Cell Immunohistochemical Pattern in Nonceliac Gluten Sensitivity. Gastroenterol Res Pract 2017; 2017:5023680. [PMID: 29362561 PMCID: PMC5738582 DOI: 10.1155/2017/5023680] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 10/29/2017] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Nonceliac gluten sensitivity (NCGS) is a gluten-related emerging condition. Since few data about NCGS histopathology is available, we assessed the markers of lymphocyte and innate immunity activation. Materials and Methods We retrieved duodenal biopsy samples of patients with NCGS diagnosis according to the Salerno criteria. We selected specimens of positive (seropositive celiac disease/Marsh 1-2 stage) and negative (normal microscopic picture) controls. Immunohistochemistry for CD3 (intraepithelial lymphocytes-IELs), CD4 (T helper lymphocytes), CD8 (T cytotoxic lymphocytes), and CD1a/CD117 (Langerhans/mast cells) was performed. ANOVA plus Bonferroni's tests were used for statistical analysis. Results Twenty NCGS, 16 celiac disease, and 16 negative controls were selected. CD3 in NCGS were higher than negative controls and lower than celiac disease (18.5 ± 6.4, 11.9 ± 2.8, and 40.8 ± 8.1 IELs/100 enterocytes; p < 0.001). CD4 were lower in NCGS than controls and celiac disease (31.0 ± 22.1, 72.5 ± 29.5, and 103.7 ± 15.7 cells/mm2; p < 0.001). CD8 in NCGS were similar to negative controls, but lower than celiac disease (14.0 ± 7.4 and 34.0 ± 7.1 IELs/100 enterocytes, p < 0.001). CD117 were higher in NCGS than celiac disease and negative controls (145.8 ± 49.9, 121.3 ± 13.1, and 113.5 ± 23.4 cells/mm2; p = 0.009). Conclusions The combination of CD4 and CD117, as well as IEL characterization, may be useful to support a clinical diagnosis of NCGS.
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Cuccioloni M, Mozzicafreddo M, Bonfili L, Cecarini V, Giangrossi M, Falconi M, Saitoh SI, Eleuteri AM, Angeletti M. Interfering with the high-affinity interaction between wheat amylase trypsin inhibitor CM3 and toll-like receptor 4: in silico and biosensor-based studies. Sci Rep 2017; 7:13169. [PMID: 29030601 PMCID: PMC5640651 DOI: 10.1038/s41598-017-13709-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/27/2017] [Indexed: 12/18/2022] Open
Abstract
Wheat amylase/trypsin bi-functional inhibitors (ATIs) are protein stimulators of innate immune response, with a recently established role in promoting both gastrointestinal and extra-gastrointestinal inflammatory syndromes. These proteins have been reported to trigger downstream intestinal inflammation upon activation of TLR4, a member of the Toll-like family of proteins that activates signalling pathways and induces the expression of immune and pro-inflammatory genes. In this study, we demonstrated the ability of ATI to directly interact with TLR4 with nanomolar affinity, and we kinetically and structurally characterized the interaction between these macromolecules by means of a concerted approach based on surface plasmon resonance binding analyses and computational studies. On the strength of these results, we designed an oligopeptide capable of preventing the formation of the complex between ATI and the receptor.
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Affiliation(s)
| | - Matteo Mozzicafreddo
- School of Biosciences and Biotechnology, University of Camerino, 62032, Camerino, Italy
| | - Laura Bonfili
- School of Biosciences and Biotechnology, University of Camerino, 62032, Camerino, Italy
| | - Valentina Cecarini
- School of Biosciences and Biotechnology, University of Camerino, 62032, Camerino, Italy
| | - Mara Giangrossi
- School of Biosciences and Biotechnology, University of Camerino, 62032, Camerino, Italy
| | - Maurizio Falconi
- School of Biosciences and Biotechnology, University of Camerino, 62032, Camerino, Italy
| | - Shin-Ichiroh Saitoh
- Division of Innate Immunity, Department of Microbiology and Immunology, The University of Tokyo, 4-6-1 Shirokanedai, Minatoku, Tokyo, 108 8639, Japan
| | - Anna Maria Eleuteri
- School of Biosciences and Biotechnology, University of Camerino, 62032, Camerino, Italy
| | - Mauro Angeletti
- School of Biosciences and Biotechnology, University of Camerino, 62032, Camerino, Italy
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Lionetti E, Pulvirenti A, Vallorani M, Catassi G, Verma AK, Gatti S, Catassi C. Re-challenge Studies in Non-celiac Gluten Sensitivity: A Systematic Review and Meta-Analysis. Front Physiol 2017; 8:621. [PMID: 28928668 PMCID: PMC5591881 DOI: 10.3389/fphys.2017.00621] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/10/2017] [Indexed: 12/18/2022] Open
Abstract
Background: Non-celiac gluten sensitivity (NCGS) is a clinical entity characterized by intestinal and/or extra-intestinal symptoms related to the ingestion of gluten in individuals that are not affected by either celiac disease (CD) or wheat allergy (WA). Since we do not have specific biomarkers for NCGS, the diagnosis is based on the evidence of a clear relationship between the ingestion of gluten (re-challenge) and clinical symptoms, after a remission during the gluten-free diet (GFD). Several re-challenge studies have been published so far to evaluate the real prevalence of NCGS, reporting conflicting results. In the present article, we provide a systematic review with meta-analysis of the existing literature on re-challenge studies to evaluate prevalence figures of NCGS after re-challenge procedures. Methods: All clinical trials performing a gluten re-challenge with or without a placebo control in patients with a suspected diagnosis of NCGS were included. Search results were limited to studies published in English language. No publication date or publication status restrictions were imposed. Results: Eleven studies were included in the meta-analysis. There was a considerable heterogeneity related to different sample size, type, and amount of gluten administered, duration of challenge and different type of placebo. The overall pooled percentage of patients with a diagnosis of NCGS relapsing after a gluten challenge was 30%, ranging between 7 and 77%. The meta-analysis showed a not significant relative risk (RR) of relapse after gluten challenge as compared to placebo (RR = 0.4; 95% CI = -0.15-0.9; p = 0.16). The overall pooled percentage of patients with a diagnosis of NCGS relapsing after a gluten challenge performed according to the recent Salerno criteria was significantly higher as compared to the percentage of patients relapsing after placebo (40 vs. 24%; p = 0.003), with a significant RR of relapse after gluten challenge as compared to placebo (RR = 2.8; 95% CI = 1.5-5.5; p = 0.002). Conclusions: The prevalence of NCGS after gluten re-challenge is low, and the percentage of relapse after a gluten or a placebo challenge is similar. However, a higher number of patients will be correctly classified with NCGS if applying the recent Salerno criteria.
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Affiliation(s)
- Elena Lionetti
- Department of Pediatrics, Università Politecnica delle MarcheAncona, Italy
| | - Alfredo Pulvirenti
- Department of Clinical and Molecular Biomedicine, Università Politecnica delle MarcheAncona, Italy
| | - Martina Vallorani
- Department of Pediatrics, Università Politecnica delle MarcheAncona, Italy
| | - Giulia Catassi
- Department of Pediatrics, Università Politecnica delle MarcheAncona, Italy
| | - Anil K Verma
- Department of Pediatrics, Università Politecnica delle MarcheAncona, Italy
| | - Simona Gatti
- Department of Pediatrics, Università Politecnica delle MarcheAncona, Italy
| | - Carlo Catassi
- Department of Pediatrics, Università Politecnica delle MarcheAncona, Italy.,Center for Celiac Research, MassGeneral Hospital for Children and the Celiac Program, Harvard Medical SchoolBoston, MA, United States
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Alvisi P, De Fazio L, Valerii MC, Cavazza E, Salerno A, Lacorte D, Dinelli G, Spisni E. Responses of blood mononucleated cells and clinical outcome of non-celiac gluten sensitive pediatric patients to various cereal sources: a pilot study. Int J Food Sci Nutr 2017; 68:1005-1012. [PMID: 28420279 DOI: 10.1080/09637486.2017.1315058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Non-celiac gluten sensitivity (NCGS) is a clinical entity recently documented by the scientific community in pediatric patients. Nevertheless, its triggering mechanisms remain largely unsettled. We studied 11 children with NCGS who were diagnosed based on a clear-cut relationship between wheat consumption and development of symptoms, after excluding celiac disease (CD) and wheat allergy, matched with 18 children with active CD. Sixteen pediatric patients were also enrolled as controls. Cultured peripheral blood mononucleated cells (PBMCs) obtained from NCGS, CD and control patients were cultured in the presence of wheat proteins extracted from ancient and modern cultivars. Results demonstrated that wheat proteins induced an overactivation of the proinflammatory chemokine CXCL10 in PBMC from NCGS pediatric patients and that this overexpression also depended on the wheat cultivar from which proteins were extracted. Proteins from modern wheat cultivar activated CXCL10 to a greater extent than those extracted from ancient wheat genotypes.
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Affiliation(s)
- Patrizia Alvisi
- a Gastroenterology of Pediatric Unit , Maggiore Hospital , Bologna , Italy
| | - Luigia De Fazio
- b Department of Biological, Geological and Environmental Sciences , University of Bologna , Bologna , Italy
| | - Maria Chiara Valerii
- b Department of Biological, Geological and Environmental Sciences , University of Bologna , Bologna , Italy
| | - Elena Cavazza
- b Department of Biological, Geological and Environmental Sciences , University of Bologna , Bologna , Italy
| | - Angela Salerno
- c Anatomy, Histology and Cytodiagnostic Unit , Maggiore Hospital , Bologna , Italy
| | - Doriana Lacorte
- d Graduate School of Pediatrics , University of Ferrara , Ferrara , Italy
| | - Giovanni Dinelli
- e Department of Agricultural Sciences , University of Bologna , Bologna , Italy
| | - Enzo Spisni
- b Department of Biological, Geological and Environmental Sciences , University of Bologna , Bologna , Italy
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Zevallos VF, Raker V, Tenzer S, Jimenez-Calvente C, Ashfaq-Khan M, Rüssel N, Pickert G, Schild H, Steinbrink K, Schuppan D. Nutritional Wheat Amylase-Trypsin Inhibitors Promote Intestinal Inflammation via Activation of Myeloid Cells. Gastroenterology 2017; 152:1100-1113.e12. [PMID: 27993525 DOI: 10.1053/j.gastro.2016.12.006] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 11/09/2016] [Accepted: 12/05/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Wheat amylase-trypsin inhibitors (ATIs) are nutritional activators of innate immunity, via activation of the toll-like receptor 4 (TLR4) on myeloid cells. We aimed to characterize the biologic activity of ATIs in various foods and their effect on intestinal inflammation. METHODS We selected 38 different gluten-containing and gluten-free products, either unprocessed (such as wheat, rye, barley, quinoa, amaranth, soya, lentils, and rice) or processed (such as pizza, pasta, bread, and biscuits). ATIs were extracted and their biological activities determined in TLR4-responsive mouse and human cell lines. Effects of oral ATIs on intestinal inflammation were determined in healthy C57BL/6 mice on a gluten-free or ATI-free diet and in mice given low-level polyinosinic:polycytidylic acid or dextran sodium sulfate to induce colitis. Parameters of innate and adaptive immune activation were determined in duodenum, ileum, colon, and mesenteric lymph nodes. RESULTS Modern gluten-containing staples had levels of TLR4-activating ATIs that were as much as 100-fold higher than in most gluten-free foods. Processed or baked foods retained ATI bioactivity. Most older wheat variants (such as Emmer or Einkorn) had lower bioactivity than modern (hexaploid) wheat. ATI species CM3 and 0.19 were the most prevalent activators of TLR4 in modern wheat and were highly resistant to intestinal proteolysis. Their ingestion induced modest intestinal myeloid cell infiltration and activation, and release of inflammatory mediators-mostly in the colon, then in the ileum, and then in the duodenum. Dendritic cells became prominently activated in mesenteric lymph nodes. Concentrations of ATIs found in a normal daily gluten-containing diet increased low-level intestinal inflammation. CONCLUSIONS Gluten-containing cereals have by far the highest concentrations of ATIs that activate TLR4. Orally ingested ATIs are largely resistant to proteases and heat, and increase intestinal inflammation by activating gut and mesenteric lymph node myeloid cells.
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Affiliation(s)
- Victor F Zevallos
- Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Verena Raker
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Stefan Tenzer
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Institute of Immunology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Carolina Jimenez-Calvente
- Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Muhammad Ashfaq-Khan
- Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Nina Rüssel
- Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Geethanjali Pickert
- Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Hansjörg Schild
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Institute of Immunology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Kerstin Steinbrink
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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Løvik A, Skodje G, Bratlie J, Brottveit M, Lundin K. Diet adherence and gluten exposure in coeliac disease and self-reported non-coeliac gluten sensitivity. Clin Nutr 2017; 36:275-280. [DOI: 10.1016/j.clnu.2015.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 11/17/2015] [Accepted: 11/25/2015] [Indexed: 12/19/2022]
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Abstract
PURPOSE OF REVIEW A new syndrome responding to gluten-free diet and defined non-celiac gluten sensitivity entered the spectrum of gluten-related disorders, together with celiac disease and wheat allergy. However, its definition, prevalence, diagnosis, pathogenesis, treatment, and follow up are still controversial. The purpose of the review is to summarize the evidence and problems emerging from the current literature. RECENT FINDINGS Direct implication of gluten in the onset of symptoms is often unproved as a low fermentable oligo-, di- and mono-saccharides and polyols diet or other components of cereals as wheat amylase trypsin inhibitor could be similarly involved. To date, no specific biomarkers or histological abnormalities confirm diagnosis, and only the self-reported response to gluten-free diet as well as a positive double blind placebo-gluten challenge characterizes these non-celiac, non-wheat allergic patients. Critical revision of published studies can offer practical indications in approaching this clinical topic and useful suggestions to standardize scientific researches.
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Affiliation(s)
- Maria Teresa Bardella
- Center for the Prevention and Diagnosis of Celiac Disease, Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122, Milan, Italy.
- , Via Giambologna, 1 - 20136, Milan, Italy.
| | - Luca Elli
- Center for the Prevention and Diagnosis of Celiac Disease, Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122, Milan, Italy
| | - Francesca Ferretti
- Center for the Prevention and Diagnosis of Celiac Disease, Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122, Milan, Italy
- Department of Medical, Surgical and Transplant Physiopathology, University of Milan, via Francesco Sforza 35, 20122, Milan, Italy
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Abstract
Nonceliac gluten sensitivity (NCGS) refers to a clinical phenotype in which patients experience intestinal and extraintestinal symptoms related to ingesting a gluten-containing diet after a diagnosis of celiac disease (CD) or wheat allergy has been excluded. CD, an autoimmune disease characterized by villous atrophy triggered by the ingestion of gluten, has increased in prevalence in recent decades, although the majority of patients remain undiagnosed. There is now an increasing public awareness of NCGS and growing interest in the health effects of gluten among health professionals and the lay public. Several randomized controlled trials have explored NCGS but have left many questions unanswered surrounding the pathophysiology, biomarkers, and established diagnostic approach to patients with this condition. Future studies are necessary to establish biomarkers and to elucidate the pathophysiology of this condition because at present, NCGS likely comprises a heterogeneous patient population. In this review, we outline the clinical trials of NCGS as well as the approach to patients with possible NCGS as recommended by an international expert panel. Because maintaining a gluten-free diet has important health, social, and economic consequences, it is necessary for medical professionals to provide practical and evidence-based advice to patients with this condition.
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Affiliation(s)
- Anna Krigel
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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42
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Volta U, Pinto-Sanchez MI, Boschetti E, Caio G, De Giorgio R, Verdu EF. Dietary Triggers in Irritable Bowel Syndrome: Is There a Role for Gluten? J Neurogastroenterol Motil 2016; 22:547-557. [PMID: 27426486 PMCID: PMC5056565 DOI: 10.5056/jnm16069] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/02/2016] [Indexed: 12/13/2022] Open
Abstract
A tight link exists between dietary factors and irritable bowel syndrome (IBS), one of the most common functional syndromes, characterized by abdominal pain/discomfort, bloating and alternating bowel habits. Amongst the variety of foods potentially evoking "food sensitivity", gluten and other wheat proteins including amylase trypsin inhibitors represent the culprits that recently have drawn the attention of the scientific community. Therefore, a newly emerging condition termed non-celiac gluten sensitivity (NCGS) or nonceliac wheat sensitivity (NCWS) is now well established in the clinical practice. Notably, patients with NCGS/NCWS have symptoms that mimic those present in IBS. The mechanisms by which gluten or other wheat proteins trigger symptoms are poorly understood and the lack of specific biomarkers hampers diagnosis of this condition. The present review aimed at providing an update to physicians and scientists regarding the following main topics: the experimental and clinical evidence on the role of gluten/wheat in IBS; how to diagnose patients with functional symptoms attributable to gluten/wheat sensitivity; the importance of double-blind placebo controlled cross-over trials as confirmatory assays of gluten/wheat sensitivity; and finally, dietary measures for gluten/wheat sensitive patients. The analysis of current evidence proposes that gluten/wheat sensitivity can indeed represent a subset of the broad spectrum of patients with a clinical presentation of IBS.
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Affiliation(s)
- Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Elisa Boschetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giacomo Caio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Roberto De Giorgio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elena F Verdu
- Department of Medicine, McMaster University, Farncombe Institute, Hamilton, Ontario, Canada
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Silvester JA, Graff LA, Rigaux L, Walker JR, Duerksen DR. Symptomatic suspected gluten exposure is common among patients with coeliac disease on a gluten-free diet. Aliment Pharmacol Ther 2016; 44:612-9. [PMID: 27443825 PMCID: PMC5283559 DOI: 10.1111/apt.13725] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 04/22/2016] [Accepted: 06/21/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND A gluten-free diet is the only recommended treatment for coeliac disease. AIM To determine the prevalence and characteristics of reactions to gluten among persons with coeliac disease on a gluten-free diet. METHODS Adults with biopsy proven, newly diagnosed coeliac disease were prospectively enrolled. A survey related to diet adherence and reactions to gluten was completed at study entry and 6 months. The Coeliac Symptom Index, Coeliac Diet Assessment Tool (CDAT) and Gluten-Free Eating Assessment Tool (GF-EAT) were used to measure coeliac disease symptoms and gluten-free diet adherence. RESULTS Of the 105 participants, 91% reported gluten exposure <1 per month and median CDAT score was 9 (IQR 8-11), consistent with adequate adherence. A suspected symptomatic reaction to gluten was reported by 66%. Gluten consumption was unsuspected until a reaction occurred (63%) or resulted from problems ordering in a restaurant (29%). The amount of gluten consumed ranged from cross-contact (30%) to a major ingredient (10%). Median time to symptom onset was 1 h (range 10 min to 48 h), and median symptom duration was 24 h (range 1 h to 8 days). Common symptoms included abdominal pain (80%), diarrhoea (52%), fatigue (33%), headache (30%) and irritability (29%). CONCLUSIONS Reactions to suspected gluten exposure are common among patients with coeliac disease on a gluten-free diet. Eating at restaurants and other peoples' homes remain a risk for unintentional gluten exposure. When following individuals with coeliac disease, clinicians should include questions regarding reactions to gluten as part of their assessment of gluten-free diet adherence.
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Affiliation(s)
- Jocelyn A Silvester
- College of Medicine, University of Manitoba, Winnipeg, MB R3E 3P5,Celiac Research Program, Harvard Medical School, 300 Brookline Avenue, Boston, MA 02215
| | | | - Lisa Rigaux
- St Boniface Hospital, 409 Tache Avenue, Winnipeg, MB R2H 2A6
| | - John R Walker
- College of Medicine, University of Manitoba, Winnipeg, MB R3E 3P5
| | - Donald R Duerksen
- College of Medicine, University of Manitoba, Winnipeg, MB R3E 3P5,St Boniface Hospital, 409 Tache Avenue, Winnipeg, MB R2H 2A6
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The starch-bound alpha-amylase/trypsin-inhibitors in Avena. Mol Genet Genomics 2016; 291:2043-2054. [PMID: 27495179 DOI: 10.1007/s00438-016-1238-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/29/2016] [Indexed: 12/15/2022]
Abstract
Oat kernels exhibit an extra-soft texture, a trait recently demonstrated to be largely modulated by starch-bound tryptophan-rich 2S proteins, the vromindolines. In this study, fractionation by two-dimensional electrophoresis of starch-bound proteins in 25 oat (Avena sativa) cultivars and 11 diploid or tetraploid Avena species revealed novel 2S proteins called Avena α-amylase/trypsin-inhibitors (AATI) because of their sequence similarity with wheat α-amylase/trypsin inhibitors. Thirty-seven AATI polypeptides, about 14 kDa in size, were split into three families named AATI-1, AATI-2, and AATI-3 with different primary structures and isoelectric points. AATI-1 and AATI-2 proteins showed 55.5-60.0 % sequence similarity with wheat α-amylase inhibitors CM1, CM2, and CM16, which have been found to cause innate immunity responses in celiac disease and non-celiac gluten sensitivity. Diploid A-genome and tetraploid AC-genome oat species possess three and five genes encoding for the AATI proteins, respectively, whereas hexaploid A. sativa exhibits 12 genes dispersed over the A-, C-, and D-genomes. Some AATI proteins expressed in hexaploid oats were assigned to the A-genome based on similarity to their counterparts in diploid species, contributing to further clarify the genetic origin of hexaploid oats. Moreover, AATI may interact with starch-bound vromindolines in determining the extra-soft texture of oat kernels and, due to their balanced amino acid compositions, may contribute to the biological value of oat proteins in a positive manner.
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Kaliszewska A, Martinez V, Laparra JM. Proinflammatory responses driven by non-gluten factors are masked when they appear associated to gliadins. Food Chem Toxicol 2016; 95:89-95. [PMID: 27377345 DOI: 10.1016/j.fct.2016.06.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 12/14/2022]
Abstract
Cereal proteins are of clinical interest because of their cytotoxic and immunogenic features being associated to allergic processes and intestinal disorders. In addition to gliadins, there has been suggested an important role for non-gluten modulating factors (nGMF) on the onset of intestinal inflammatory processes. In this study, the amino acid sequences generated after a simulated human gastrointestinal (sGI) digestion of a commercial extract of gliadins (GEF) and the nGMF-enriched fraction (nGEF) obtained from them were characterized (nanoESI-qQTOF). These fractions were fed (20 days) to Wistar rats, sensitized with interferon (IFN)-γ (1000 IU/rat) and further treated with indomethacin (2 mg/kg). The production of inflammatory mediators (ELISAs) and the expression (rt-qPCR) of innate biomarkers was monitored in duodenal tissue sections. There were also evaluated changes in defined leukocyte (flow cytometry) populations quantified in peripheral blood samples. Expected nGMF components, CM3 and 0.19, as well as toxic gliadin-derived peptides were generated after sGI digestion. Rats fed with the nGEF showed higher concentrations of IFNγ, as well as expression levels of TLR-4 and the peroxisome proliferator activated receptor-α in duodenal samples than those animals fed with GEF. Rats fed with GEF showed higher expression levels of the endocannabinoid receptor-1 and an increased CD4(+)CD3(+)Foxp3(+) cell population. The data points out significant different cytotoxic and immunogenic potential of the nGEF when administered independently of the GEF to which are commonly associated. However, proinflammatory responses to nGMF are masked when present associated to gliadins.
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Affiliation(s)
- A Kaliszewska
- Institute of Animal Reproduction and Food Research of the Polish Academy of Sciences, Department of Immunology and Food Microbiology, Tuwima str 10, 10-748, Olsztyn, Poland
| | - V Martinez
- Immunonutrition and Health Group, Valencian International University, C/ Gorgos 5-7, 46021, Valencia, Spain
| | - J M Laparra
- Immunonutrition and Health Group, Valencian International University, C/ Gorgos 5-7, 46021, Valencia, Spain.
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The Overlap between Irritable Bowel Syndrome and Non-Celiac Gluten Sensitivity: A Clinical Dilemma. Nutrients 2015; 7:10417-26. [PMID: 26690475 PMCID: PMC4690093 DOI: 10.3390/nu7125541] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 11/25/2015] [Accepted: 12/04/2015] [Indexed: 12/21/2022] Open
Abstract
The spectrum of gluten-related disorders has widened in recent times and includes celiac disease, non-celiac gluten sensitivity, and wheat allergy. The complex of symptoms associated with these diseases, such as diarrhea, constipation or abdominal pain may overlap for the gluten related diseases, and furthermore they can be similar to those caused by various other intestinal diseases, such as irritable bowel syndrome (IBS). The mechanisms underlying symptom generation are diverse for all these diseases. Some patients with celiac disease may remain asymptomatic or have only mild gastrointestinal symptoms and thus may qualify for the diagnosis of IBS in the general clinical practice. Similarly, the overlap of symptoms between IBS and non-celiac gluten sensitivity (NCGS) often creates a dilemma for clinicians. While the treatment of NCGS is exclusion of gluten from the diet, some, but not all, of the patients with IBS also improve on a gluten-free diet. Both IBS and NCGS are common in the general population and both can coexist with each other independently without necessarily sharing a common pathophysiological basis. Although the pathogenesis of NCGS is not well understood, it is likely to be heterogeneous with possible contributing factors such as low-grade intestinal inflammation, increased intestinal barrier function and changes in the intestinal microbiota. Innate immunity may also play a pivotal role. One possible inducer of innate immune response has recently been reported to be amylase-trypsin inhibitor, a protein present in wheat endosperm and the source of flour, along with the gluten proteins.
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47
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Abstract
PURPOSE OF REVIEW Noncoeliac gluten sensitivity (NCGS) has gained attention as an emerging clinical entity. Data regarding the epidemiology, pathogenesis, and management of NCGS are scattered in view of the diagnostic uncertainty surrounding the disorder. We aim to provide a current perspective of NCGS and its associated controversies. RECENT FINDINGS NCGS consists of a spectrum of intestinal and extraintestinal symptoms related to the ingestion of gluten-containing food, yet in the absence of coeliac disease or wheat allergy. To date, no specific biomarker exists for NCGS, thereby leaving the diagnosis to be confirmed by dietary elimination followed by double-blind placebo-controlled gluten-based rechallenges. Unfortunately, this technique is cumbersome, not readily-available in routine clinical practise, and can still leave the diagnosis of NCGS open to debate as to whether the effects demonstrated can be specifically attributed to the gluten-protein per se or rather coexisting nongluten components, such as fermentable carbohydrates and amylase-trypsin inhibitors. SUMMARY Physicians are increasingly being posed with the dilemma of patients presenting with self-reported NCGS. However, this appears to be the tip of the iceberg and future studies are in need of delineating which gluten-based component is responsible for each individual patient's complaint.
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Affiliation(s)
- Federica Branchi
- aAcademic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK bGastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy *Federica Branchi and Imran Aziz contributed equally to the writing of this article
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