Talk:Coeliac disease

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Coeliac/Celiac: Please read prior discussions regarding the name of this article at /Archive 1#Requested move.

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This article was selected on the Medicine portal as one of Wikipedia's best articles related to Medicine.

1 What happens after diagnosis?
- 1.1 Comments from ImperfectlyInformed
2 NICE
3 Sorting
4 Reviews
5 Social and religious issues
- 5.1 Relative abundance of gluten-sensitive disease
6 Changes to diet section
7 Prolamin section
8 Use of the word gluten
9 Adding a mention of gluten sensitivity to the lead
10 Reliable sources
11 Idiopathic Gluten Sensitivity
12 A review on innate responses in coeliac disease
13 Diagnosis controversy, casein sensitivity, and budesonide as experimental
- 13.1 NIH concensus-Hill
14 Misunderstanding of secondary in the context of primary studies and reviews
15 Need for diagnostics
16 2007 review from NEJM
17 Proposed changes to Prolamin section
- 17.1 Back ground info on DQ2.5 and DQ2.2
- 17.2 Rewrite
18 Reviews
19 The devil is in the details
20 Indo-European
21 Genetics Section
22 AH8.1
23 Infection risk
24 Do we need nasty images without warnings?
25 Modified Marsh
26 External Links Questions

[edit] What happens after diagnosis?

This page summarily states that in the vast majority of cases, all symptoms resolve. The review cited does not appear to be focused specifically on post-diagnosis. I feel like the truth may be more complicated, and several papers back me up this, but I'm having trouble finding reviews. —This is part of a comment by ImperfectlyInformed (of 12:12, June 14, 2008 ), which was interrupted by the following:

Those quality of life issues are not so well appreciated, as we can see above. But there are limitations on the most effective size of this page. —Preceding unsigned comment added by Pdeitiker (talk • contribs) 22:05, June 14, 2008

I put together a list of PubMed abstracts; they're pretty evenly divided on the quality of life and results after diagnosis. I think this deserves more attention in this article. ImpIn | (t - c) 12:12, 14 June 2008 (UTC)

Further information: Gluten-sensitive enteropathy associated conditions

Some of, or similar pubmed links are referenced there. You can add information or please create a new section in the talk page.

As you can see there is too much associated disease to mention on this page.

Pdeitiker (talk) 22:05, 14 June 2008 (UTC)

The article says no such thing. Diarrhoea and digestive system symptoms tend to improve a lot. The article quotes a good study that says that many people continue to experience symptoms. Also: we cannot possibly cite all the articles you are referring to. Could you identify a free article with a wide scope? JFW | T@lk 09:14, 15 June 2008 (UTC)

In fact, PMID 17305757 (which is in your list) is already being cited and discussed. It is the best of the 13 papers you have linked. JFW | T@lk 09:26, 15 June 2008 (UTC)

He did not provide a proper link. Here are the articles he linked to (see edit page):

"I put together a [http://www.ncbi.nlm.nih.gov/pubmed/18372595,17644056,18372595,18176960,14624151,17305757,12088289,14705832,18176960,17470666,9759948,16772832,11346203 list of PubMed abstracts]; they're pretty evenly divided on the quality of life and results after diagnosis."

18372595-PubMed

17644056-PubMed

18372595-PubMed

18176960-PubMed

14624151-PubMed

17305757-PubMed

12088289-PubMed " Concerns about the burden of a gluten-free diet, at least over the short term, may be unfounded."

14705832-PubMed Precise information that suppliments information on GSEAC page?

18176960-PubMed GastroIntest Quality life index better in patients on a GFD than in non-treated patients. "Variables significantly associated with a worse HRQOL score were female gender, failure to adhere to a GFD, and symptomatic status."

17470666-PubMed To be added to associated conditions page.

9759948-PubMed Need more details.

16772832-PubMed 23% did not adhere to GFD to explain some symptoms

11346203-PubMed reference 86 below

Here is a selection from GEA Associated conditions:

"Alopecia areata

GSE has been found to be associated with alopecia areata (patchy baldness) [44] whereas regrowth did not necessarily occur on a gluten free diet. [45][46]"

"Diseases of the pancreas, gall bladder, bile duct

Primary biliary cirrhosis. CD is prevalent in primary biliary cirrhosis (PBC)[67][68]. In PBC anti-mitochondrial antibodies are directed toward 3 mitochondrial autoantigens (pyruvate dehydrogenase, oxoglutarate dehydrogenase,branched-chain alpha-keto acid dehydrogenase), 2 or more nuclear proteins (nucleoporin 210kDa, nucleoporin 62kDa, centromere protein, and sp100), and 57% of acute liver failure patients have anti-transglutaminase antibodies."

"Depression

Depression in GSE has several causes, in the more severe CD depression can be the result of lower vitamin adsorption[10] and essential fatty acid adsorption (see section on autism). Depression and anger may also be the result of lower quality of life issues as a result of gluten-free diet.[85] Depression appears to persist on gluten free diet in a sizable fraction of GSE.[86] Elevated anger has been noted also with GSE."

This particular aspect is backed up by a half-dozen references, if not more.

"Anxiety

Anxiety is a common feature of GSE, treatment on a gluten-free diet is effective at reducing anxiety, some aspect of which may be due to maladsorption phenomena and cytokine activity (i.e. constant stress). More resolution of anxiety is expected on gluten free diet.[86]"

This one is to be corrected with new information.

Dump from other article refactored

And returned.

And others, it goes on to mention refractory disease, RCD2, EATL, etc. Pubmed of celiac diease produces 14,000 papers, the associated conditions article has 116 references.

Yes, and you've done a great job at being rather unselective. Not everything that appears in print is relevant for a general encyclopedia. I have taking the liberty of refactoring a sampling of gluten-sensitive enteropathy associated conditions.

Yes and it was returned, this is a talk page. I agree that most of the abstracts he presented were not worthy on either page, but implying that less than 1:100 articles are worthy of referencing here is not justified.Pdeitiker (talk) 16:54, 16 June 2008 (UTC)

To be more precise: just because someone cobbles together a few case reports on "wow, a rare condition in someone with coeliac" doesn't mean it needs citing here or anywhere on Wikipedia. When strict rules on clinical causation are applied, the links are often flimsy in the extreme.

I believe I have cited, above, an article rather critical of the concept of "neuro-coeliac". JFW | T@lk 16:15, 16 June 2008 (UTC)

To be more even precise: link to the paper you cite again, so it's more clear. There are lots of links flying around. Are you referring to PMID 17305757, which you said was the best of the 13? Here's what that says:

Studies on the impact of CD and gluten-free diet (GFD) on HRQOL led to conflicting results. Whereas US-American,3 Canadian studies4 and Swedish5, 6 studies reported an average HRQOL of adult coeliac patients comparable with the general population, studies conducted in Italy,7 Northern Ireland8 and Germany 9 demonstrated a reduced HRQOL compared with the general population healthy controls, respectively. The results of the studies on HRQOL in CD are not fully comparable because they partially used different health measures. Moreover, the scope of demographic (socioeconomic factors, for example) and disease-related factors (somatic and mental comorbidities) assessed within these studies was different.

I don't see a lot of evidence for this assertion that "in the vast majority of cases all symptoms resolve". I'll be looking into improving the section at some point. ImpIn | (t - c) 22:48, 16 June 2008 (UTC)

But how selective were those clinicians in excluding oats from a gluten-free diet? One paper, no testing of quality? The restriction of oats from a gluten free diet was based on one study, that no-one else could reproduce in the 1950s, and yet you seem that this is the status-quo. This is a turf-war, not a good-science versus bad-science discussion.

We have got the citation of 6 genetic loci that other papers can't support. Should anything but HLA-DQ be in the genetics section.

A little more calm here is due. You may be surpised that some of those that have literary support were markedly reduced from selections (sometimes as many as a dozen papers in support). Whereas I see many articles on wikipedia, for example one article claimed that MCR1 in humans came from Neandertals based on one paper. I could have easily had multiple references in that pages with 1000 references cited in GSEAC.

I would also point out that most of these conditions I included in the page were picked up in discussions between celiacs, after which I investigated whether or not there is clinical evidence or not.

Why does this page spend so much time on meta-issues (like church positions), should not that bandwidth be devoted to more health related things. Aren't the religious issues "quality of life issues", why spend so much on church issues and so little time on persistent health issues that affect quality of life. Also the history section contains a number of cites that are ambiguous and weak, both the religious and history section need refactoring.Pdeitiker (talk) 16:54, 16 June 2008 (UTC)

Phil, while you are asking for calm you are continuously waffling on the talk page without making the slightest attempt to improve the article. That is starting to annoy me. You keep on dumping enormous amounts of text here, knowing quite well that nobody monitors this page apart from me and one or two other souls. Are you expecting a response? Or are you using this as your personal Reference Manager?

If you have issues with the oats question, please provide the right papers that address clinical questions and not studies on rat epithelium or somesuch. If you want the genetics content to improve, be bold. But stop lamenting.

Your parallels with the MCR1 article are WP:OTHERSTUFFEXISTS and I will not address them separately.

We are addressing church positions because this is a general purpose encyclopedia that deals with real-life issues beyond whether oats are safe etc etc. As an encyclopedia we need to be discussing the social dimension of scientific subjects in a way that medical textbooks would not ordinarily do. If the information is out there, and is notable, we should be dealing with it. I really don't understand what is so difficult about that. Similarly, the history section is just fine and you'd do best to keep your hands off it. JFW | T@lk 19:41, 16 June 2008 (UTC)

The free-access review Complications of coeliac disease: are all patients at risk? gives an expert overview of the topic. See the section on "Quality of life", where it states that in one survey 77% of patients had improved quality of life after diagnosis, but that anxiety and depression are still relatively common. Tim Vickers (talk) 20:46, 16 June 2008 (UTC)

"the history section is just fine and you'd do best to keep your hands off it"

"deals with real-life issues beyond whether oats are safe etc etc"

"please provide the ***right*** papers that address clinical questions and not studies on rat epithelium or somesuch" [Who determines for this page what is right?]

Truth lies at the intersection of valid perspectives. The more valid perspectives we have on the truth the more likely we are to know where truth can be found. Pdeitiker (talk) 22:03, 16 June 2008 (UTC)

QOL issues are out there, they have been discussed here, although they are underrepresented on this page. I did create a page on Oat sensitivity, that removed some of the pressure on the The oat controversy, which is on two pages. I suggest you read the section, you may find your 'stardard' is about to change.

P.S. I think that it is particularly unfair that a standard based on one or few poor studies become the 'null hypothesis' that somehow needs to be disproven. I also know what celiacs are discussing, and one of the major issues are recurrent conditions on GF diet.

Pdeitiker (talk)

You don't need to quote my words back at me. Wikipedia is not about WP:TRUTH. It is about consensus. There is no consensus on any of the topics we have been discussing, because I cannot agree with your insistence on making such a fuss over oats and genetics, and I certainly cannot agree with your suggestion that the "social issues" and "history" sections should be curtailed. I think it would be helpful if we worked towards consensus.

You keep on saying that the QOL issues are underrepresented. Yet, you have not made an attempt (WP:BOLD) to rectify this imbalance. The same applies to all other areas you are so passionate about. Your only recent contribution is the insertion of two laboratory studies in a section on the clinical safety of grains. Are you actually surprised that I reverted you on that?

If you have a beef with the guidelines, go complain to them. But from a professional perspective the guidelines remain the gold standard until they are updated or overwhelmingly strong evidence displaces the guidelines. I see no overwhelmingly strong evidence. All I see is an enormous flurry of studies, many of which are less than methodologically sound. I think we should take Tim Vickers' clue (below) to restrict ourselves to review articles. JFW | T@lk 22:21, 16 June 2008 (UTC)

Keeping short Then we need to discuss issues before change, I am not going to be BOLD with a 95% chance you will revert the change, If I argue there is clinical evidence that oats are safe for celiacs, then your response should be what is the evidence, provide the papers. Next you critique the evidence. Then we agree what is the best references, the statement is added. Again I added 4 references, 2 on the grains and 2 specifically on oats, it is still apparent you read neither on oats. Here are the clinical references on oat safety PubMed:4417208, PubMed:7675045, PubMed:8942690,PubMed:10969261, PubMed:10969261, PubMed:11839710, PubMed:12377824 PubMed:12548312, PubMed:15082581, PubMed:16669961, {{|10673292}} New standards for gluten free foods That should be convincing enough.

At least have the courtesy of crop what was cut and pasting it here for discussion, people make faux-pas. So point to that which is in error.

Lets consider the gold standards: -Oat causes celiac disease - false for >90% of patients. -Clinical atrophy is the only indicator of gluten-sensitive atrophy. -- Even the first studies noted patchy villus atrophy, ignored. Current investigations recommend 8 biopsiess descending away from the duodenum. -- Increased incidences of AID and gastro problems seen in Marsh grade 1 and 2 (sub-clinical) coeliac disease. -- Coeliac disease can be diagnosed with Gene-typing and ATA typing, no great need for biopsy. Standards can be obsolete or wrong. The standard for Oats in GF diet was from 1981, it was apparent that something was amiss by 2003. Through the primary literature we can separate those standards based on facts and those standards based on beleif. While the function of wiki is not to find the truth, it certainly wants to screen out that which is provably not true. This I see as a basic problem. I have seen several sections on oats in Wiki, none of them give any information on the science, or even point to the standard. That is not encyclopedic information, that is simply myth.

I came to a solution, maybe that was the best solution, anyway. I moved the oat controversy off page. What I would like on the main page is {{further|[[Oat_sensitivity]]}} and {{Further|[[Gluten sensitivity#The oat controversy|The oat controversy in gluten sensitivity]]}}. Pdeitiker (talk) 23:26, 16 June 2008 (UTC)

Here's my take:

Take Tim Vickers' suggestion and only rely on the conclusions of review articles and meta-analyses. This way you don't fall foul of WP:NOR and WP:SYNTH, and you stand a chance that I will support your edits wholeheartedly.
There is presently a professional consensus that oats (i.e. grain products guaranteed not to contain gluten) should be consumed with caution: initially avoid them completely, then reintroduce them while accepting that repeat biopsies or serology may be needed, either routinely or on reappearance of symptoms. This is supported by the two reviews that Tim has kindly identified.
AID and "gastro problems" are really vague terms, and the studies that show this are methodologically weak. The same on gluten neuropathies.
Professional guidelines demand biopsy, and this is professional consensus until the guidelines are updated or displaced by large prospective studies. Perhaps next year NICE will alter practice in the United Kingdom. Until then we can only do so much in mentioning the diagnosis of coeliac disease sans biopsy.
I can't presently support links to oat sensitivity (a neologism) and the oat controversy. With the reviews in our hand we can provide a balanced account of the issues without having to resort to subarticles. JFW | T@lk 23:53, 16 June 2008 (UTC)

When it comes to credibility in science 1. Primary literature, 2. Reviews, 3. Books, 4. Newspaper articles about 1, 2 and 3. I look whenever possible at the original data. When it comes to timeliness 1. Primary literature 2. Newspaper 3. reviews 4. books.

Pardon me for cutting in here. Why can't we just say what you just said? Provide references (I have those by T. Thompson ready to go). BTW, Thompson states the major reason for taking care is the contamination issue. Just crop it an cite it. Pdeitiker (talk) 01:35, 17 June 2008 (UTC)

Yes, but those studies that have followed up celiacs have found a broad smattering of AID that are generally persistent or recurrent on gluten-free diet. QOL issue.Pdeitiker (talk) 01:35, 17 June 2008 (UTC)

I agree, but patient perspective, here, again QOL. Low cut insurance providers and 15 minute physicians, they don't want to do biopsies until after the tests come back if that, now-a-days, the will ask the patient if they need a biopsy. I don't know what you have to deal with, but I know what I and a couple of other gluten-sensitive individuals have had to deal with. Patients have to deal with the system as it exists, not as someone in a far off country wishes it might be.Pdeitiker (talk) 01:35, 17 June 2008 (UTC)

I have again disentangled your comments from my bulleted list. Please follow talk page guidelines. I have asked you previously to leave my posts intact.

Credibility in science is not primarily in the primary literature. Please review WP:MEDRS. Reviews have the benefit of having a full survey of the published knowledge on a subject. This is something a primary research study cannot provide. Please also see Tim Vickers' points below and a separate discussion with ImperfectlyInformed. The central place of review studies is not really open to discussion here.

You are free to insert my version of the oat issue with the appropriate reference.

No, AID studies need to be reliable and causally plausible. This is presently lacking. It is not just a QOL issue, it is a treatment issue and a monitoring issue and a screening issue.

I have no idea what relevance "patient perspective" has in this discussion, nor your jibe at 15 minute physicians. If professional guidelines insist on biopsy, then those doctors or organisations deviating from this guideline open themselves up to criticism. Who is "someone in a far off country"? I really don't understand your points here. JFW | T@lk 01:55, 17 June 2008 (UTC)

[edit] Comments from ImperfectlyInformed

First, what's wrong with referencing all those PMIDs with one link, Pdeitiker? Anyway, I agree with Tim about using reviews, I just couldn't find any good ones. Thanks for pointing this BMJ one out. Here's what it says on quality of life:

Arguably, most people with either diagnosed or undiagnosed coeliac disease have only minor symptoms that are more inconvenient than life threatening, but is this really true? The few data available regarding quality of life of patients with coeliac disease suggest that health-related quality of life and psychological general well-being are poor in undiagnosed patients, and improve with treatment in men but not significantly in women. This difference between sexes was explained by a greater reporting of symptoms by women in remission, implying factors beyond normalisation of the intestinal mucosa.40,41 In the US, 1612 respondents to a postal questionnaire reported a mean duration of symptoms for 11 years before the diagnosis of coeliac disease was made; after treatment 77% had an improved quality of life.17 A high prevalence of depression was well documented in patients with coeliac disease.42 In comparison with controls, anxiety and depression are much more common (71% v 23%; p<0.001 and 57% v 10%; p<0.001, respectively) and tend to improve, but not normalise, after 1 year on a GFD.43

– http://pmj.bmj.com/cgi/content/full/82/973/705

My personal feelings on the issue is that recurring problems could be largely attributable to ubiquitous gluten contamination, but I'd like to see what is said about this in the papers. In Europe, for example, maltodextrin is frequently made from wheat while in the US is made from corn (rough source). I'm sure you've mostly heard that. Many people eat packaged foods, or foods with no gluten ingredients, and gluten is frequently in them -- even in very small, allowed amounts. Reference 99 (PMID 10499479) from the BMJ review highlights this issue and claims that many of these symptoms resolve on a completely gluten-free diet -- which probably requires cooking more from scratch than most people do. ImpIn | (t - c) 22:48, 16 June 2008 (UTC)

I think it is not helpful to offer long quotes and personal feelings. Please WP:BOLD and improve the article. JFW | T@lk 23:00, 16 June 2008 (UTC)

Don't assume that every little roadbump in a coeliacs life is due to gluten.Pdeitiker (talk) 05:43, 17 June 2008 (UTC)

[edit] NICE

I think I understand why the BSG has been slow in issuing formal guidelines, given that Prof Ciclitira's guidelines are now 6 years old. The reason is that NICE are working on a clinical guideline for coeliac in adults: http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11880. Looking at the list of stakeholders I am puzzled by the involvement of NHS Direct (since when is coeliac disease a medical emergency?), the National Treatment Agency for Substance Misuse (since when are coeliacs addicts?), and the South Asian Health Foundation (coeliac disease is rather rare in South Asians). I'm sure we'll need to update this article when the guideline appears - it has been scheduled for May 2009. JFW | T@lk 09:26, 15 June 2008 (UTC)

[edit] Sorting

It's rather hard to sort the conversation on this page because WP:TALK page conventions aren't being followed: Pdeitiker, would you mind not altering other editors' comments,[1] signing your edits, and threading your responses under the posts you are responding to? The conversation would be easier to follow if you didn't split up other editors' commentary (see WP:TP and WP:TALK). SandyGeorgia (Talk) 20:23, 16 June 2008 (UTC)

[edit] Reviews

This talkpage could be greatly improved if editors relied more heavily on reviews of the topic, rather than referring to personal anecdotes or going through the primary literature themselves and trying to make sense of the large set of conflicting data on this topic. Reviews and meta-analyzes give an expert overview that is much more reliable than trying to integrate several individual studies that each deal with a narrow topic. Tim Vickers (talk) 20:55, 16 June 2008 (UTC)

Most papers have succint reviews of the literature in their introduction and discussion sections, which are usually fairly easy to understand. ImpIn | (t - c) 22:48, 16 June 2008 (UTC)

Indeed, but if you want to, for example, look at how safe oats are in a gluten-free diet, the best approach is to find a few reviews that examine the topic of how safe oats are in these diets and describe the conclusions of these reviews in the article, rather than selecting papers out of the primary research literature yourself and then synthesizing the conclusions of these papers to form your own view of the field. Expert reviews are the preferred sources for these kind of general articles. Tim Vickers (talk) 16:35, 17 June 2008 (UTC)

[edit] Social and religious issues

Since we have this in discussion.

This section is redundant with a similarly long section "Religious issues" in Dermatitis herpetiformis. Both articles over-deal with the issue and do not deal with other issues that affect quality of life, including depression, anxiety and anger.
This section pertains to all gluten sensitivity, not just celiac disease. If it was moved to gluten sensitivity it would not need to be dealt with twice.
This issue is pertinent only to Westerners and those who practice certain religions, at such it can be simplified and shortened.
An alternative is to create a new article "Religious issues in gluten sensitivity". This would allow more bandwidth for discussion of other issues.Pdeitiker (talk) 22:37, 16 June 2008 (UTC)

1. Since this article is a featured article, it needs to be comprehensive; what is at Dermatitis herpetiformis isn't relevant here. Depression, anxiety and anger are given due weight according to reliable reviews.
2. See WP:NOT paper.
3. It's not too long or complex.
4. Shortening of this article isn't necessary; comprehensiveness is the main concern. SandyGeorgia (Talk) 22:49, 16 June 2008 (UTC)

I think that mentioning and linking off to a separate article on gluten sensitivity and religious issues, or gluten sensitivity and lifestyle has merit. It's better not to replicate a broad issue like that a bunch of times; it's tiresome for readers to read the same thing over and over, and it is, as Pdeitiker, not directly relevant to coeliac disease, but more directly relevant to coeliac sensitivity. Also, this article should link to gluten sensitivity in the lead, and briefly mention the relationship of the disease to the broader sensitivity affecting people w/o the disease. ImpIn | (t - c) 22:54, 16 June 2008 (UTC)

This section is not being split off. Coeliac disease is the most common form of gluten sensitivity, and the other articles can link here for the content in question.

I don't think there is any need to link to gluten sensitivity from the lead. Gluten sensitivity is already linked very prominently from the infobox that Phil inserted. Moreover, coeliac disease is a very specific subtype of gluten sensitivity. JFW | T@lk 22:58, 16 June 2008 (UTC)

OK. You need to read OWN very carefully, JFW, because you're showing serious symptoms of thinking you own this article. We will decide as a group whether to split off a section -- not you. Sorry. Also, you need to think about improving your tone, because you're not the only temperamental person around. The gluten sensitivity infobox is not all that prominent -- I missed it several times, especially because I tend to click on a section directly from the lead. This article also needs to discuss self-diagnosed "coeliac disease" -- I am self-diagnosed, as are most "coeliacs" that I meet, because once you go off gluten and have great results, it is hard to start eating it again just to have an intestinal biopsy. I have one of the genes for it, a gene for sensitivity, and pretty much all of the symptoms (including positive serology). PMID 10896066 provides some background, as does PMID 17919990. Here is a letter discussing the issue. ImpIn | (t - c) 23:08, 16 June 2008 (UTC)

Self-diagnosis could be discussed if reliable, high-quality reviews address the topic; if not, we must take care with WP:UNDUE and not rely on primary sources. II, please avoid inflammatory discussions with other editors, if you have personal issues, please take them to individual editor talk pages, thanks, SandyGeorgia (Talk) 23:11, 16 June 2008 (UTC)

This is a talkpage, and I thought I should make my opinion clear. That isn't WP:OWN and I would obviously yield to articulate and reasonable consensus. I am one of the editors who worked very hard to get this article up to featured status in 2007 so I hope you will forgive me of being somewhat protective of it.

I am really not sure if self-diagnosis is to be mentioned. In the end, anyone who self-diagnoses still needs to undergo confirmatory testing by qualified healthcare professionals. JFW | T@lk 23:25, 16 June 2008 (UTC)

That is not consistent with policy; we are not restricted to using only reviews of literature. Read [[WP:OR#PSTS|]]. The discussion sections of specialized papers are often better than the very brief and general notes in a review of the literature such as the one posted by Tim. Much of the systematic reviewing of specialized literature goes on in later primary papers themselves. I've opened up a discussion on this at the OR talk page, which I will probably open into a RfCpol. ImpIn | (t - c) 23:40, 16 June 2008 (UTC)

Yes, please do read WP:OR#PSTS

Wikipedia articles should rely on reliable, published secondary sources. All interpretive claims, analyses, or synthetic claims about primary sources must be referenced to a secondary source, rather than original analysis of the primary-source material by Wikipedia editors. ... Primary sources that have been published by a reliable source may be used in Wikipedia, but only with care, because it is easy to misuse them.

SandyGeorgia (Talk) 14:34, 17 June 2008 (UTC)

Sandy, read further. Primary articles may be used if they are clear. Plus, technically speaking, a primary review discussing past literature is a secondary source of information on that literature. The idea that reviews always are more comprehensive is a poor assumption. Look at the review that Tim posted. All it basically does is collect all the reviews on one page. It offers very little analysis. Please reply. ImpIn | (t - c) 10:57, 18 June 2008 (UTC)

Policy is that you cannot use a single primary reference to refute a review unless that primary reference is primarily questioning an opinion in the review. Thats what I understand. For example you cannot take something from the discussion of a paper in 1963 to refute an opinion in an 1980 review. OTOH you can use results from a 2008 paper to refute an statement in a review from 1980 if recent paper is specifically directed at the except from the review used.Pdeitiker (talk) 02:01, 17 June 2008 (UTC)

Well yeah, don't get ridiculous. Using more recent articles is preferable. When you cite a certain thing, the one which has the most support behind it (papers, or more specifically data) is the one with the most strength. But the idea that the review necessarily improves this is fallacious. The PMJ linked by Tim, as I've pointed out a couple times, offers very little analysis, and this is not uncommon in reviews, especially those with a broad scope. ImpIn | (t - c) 10:57, 18 June 2008 (UTC)

There is no such policy. SandyGeorgia (Talk) 14:34, 17 June 2008 (UTC)

There is no such provision in the WP:Verifiability policy. I should know, I helped write the darned thing. Tim Vickers (talk) 16:38, 17 June 2008 (UTC)

"All articles must adhere to Wikipedia's neutrality policy, fairly representing all majority and significant-minority viewpoints that have been published by reliable sources, in rough proportion to the prominence of each view." "In general, the most reliable sources are peer-reviewed journals and books published in university presses; university-level textbooks; magazines, journals, and books published by respected publishing houses; and mainstream newspapers. As a rule of thumb, the greater the degree of scrutiny involved in checking facts, analyzing legal issues, and scrutinizing the evidence and arguments of a particular work, the more reliable it is.""For a guideline discussing the reliability of particular types of sources, see Wikipedia:Reliable sources (WP:RS). Because policies take precedence over guidelines, in the case of an inconsistency between this page and that one." If the contradiction isn't obvious, then maybe I live in an alternate universe. This _policy_ says nothing about the precedence of a review over primary literature or restictions on contradicting a review opinion with primary literature. But here in WP:NOR we see "Wikipedia articles should rely on reliable, published secondary sources. All interpretive claims, analyses, or synthetic claims about primary sources must be referenced to a secondary source, rather than original analysis of the primary-source material by Wikipedia editors." and then "Appropriate sourcing can be a complicated issue, and these are general rules. Deciding whether primary or secondary sources are more suitable on any given occasion is a matter of common sense and good editorial judgment, and should be discussed on article talk pages."(ahem)Pdeitiker (talk) 20:45, 17 June 2008 (UTC) Concrete is what we build houses on, not the direction that desires the mind.

Yoda confused is he, as policy say, prefer to use secondary sources we do. :) Tim Vickers (talk) 23:34, 17 June 2008 (UTC)

Thanks for making that clear. I can understand being protective about it. As far as confirmatory testing, it often does not happen because its uncomfortable and considered by patients (and some doctors) to be largely unnecessary if they feel much better. ***Couple other interesting papers semi-related: physician knowledge of the disease, and prescribing the GF diet without a biopsy. ImpIn | (t - c) 23:40, 16 June 2008 (UTC)

Self-diagnosis belongs on the gluten-sensitivity page. Pdeitiker (talk) 23:28, 16 June 2008 (UTC)

Self-diagnosis of coeliac disease belonging somewhere that is not not the coeliac disease page? Now I'm confused. What would the point of that be? JFW | T@lk 23:53, 16 June 2008 (UTC)

Self-diagnosis belongs nowhere unless it's discussed by reliable secondary sources. SandyGeorgia (Talk) 14:34, 17 June 2008 (UTC)

Non-diagnosis, without ATA & Gene typing or biopsy (preferably looking for IEL or ATA deposits), accompanied by a decrease of symptoms on a gluten-free diet is gluten sensitivity (GS). GS can be divided into gluten-sensitive enteropathy (stage 3 and 4 = coeliac disease). GS can also be an allergy to gluten or wheat. I know of people who firmly believed they had coeliac disease until they were tested, upon testing for food allergies they found they were allergic to wheat. There was a recent study done on gluten exclusion diet with I believe 116 people, the affected consented to gluten-challenge however only half were confirmed as coeliac disease. Studies show that there are about 3 times as many people allergic to wheat as those who are coeliacs. If you need references I can find them for you.Pdeitiker (talk) 01:43, 17 June 2008 (UTC).

To respond to ImperfectlyInformed: there is a certain hierarchy in medical sources, and WP:MEDRS accords preference to reviews and meta-analyses pretty much the way professional guidelines prefer that kind of study over isolated reports that have not been replicated.

I take your point on a GF diet without biopsy, but this is presently being discouraged as professional guidelines still regard the biopsy is crucial. If people decline to undergo a biopsy they run the risk of treating themselves for nonexisting coeliac disease, however close one gets to a diagnosis with serology and HLA typing. JFW | T@lk 23:53, 16 June 2008 (UTC)

I don't disagree with you, but I think the self-diagnosis phenomenon needs to be noted carefully in the diagnosis section. I'll do this shortly after more research. As the letter I cited shows, there is some controversy surrounding the biopsy, and that deserves a sentence or two. After that, I strongly think that gluten sensitivity needs to be noted in the lead where it is harder to miss. And possibly there needs to be a section discussing the relationship between gluten sens. and coeliac disease -- I'm sure there are papers on it. ImpIn | (t - c) 10:57, 18 June 2008 (UTC)

[edit] Relative abundance of gluten-sensitive disease

The abundance of coeliac disease. Frequency of coeliac disease in the population is age dependent. See section in Main on tissue transglutaminase and section in talk page on coeliac disease in the elderly. Excluding death as a result of coeliac related conditions the rate appears to climb from about 0.5% to greater than 1.5% over a lifetime. The retrospective studies on biopsies of suspected coeliacs reveal that a small percentage of people, at any one time, are within the Marsh grade 1 and 2 criteria, a process that last up to 5 years. Asymptomatic coeliac disease represents the majority of the coeliac population, the level of diagnosis depends on the country, the Scandinavian countries appear to have the highest rate of diagnosis.

The abundance of allergies. I have seen estimates in the literature that wheat allergy ranges as high as 5% though most place rate of allergy below 3%. Thoroughness of testing is the major deterrent to accurate estimates. The ability to detect wheat allergy depends on the type of testing, and other allergies like ASCA and amylase antibodies that are screened-out. Most wheat allergies are not apparent to the individual, and may be asymptomatic unless they work in an occupation that makes or processes wheat products. In general, the separation of wheat allergies into gluten allergies is not done. Gluten allergies are estimated to be about 1/2 of all wheat allergies. The most severe wheat allergy, to omega-5 gliadin is very rare, but is increasing with the use of aspirin, NSAIDs and low dose aspiring therapy. Most allergies are to the glutenin component of wheat. Mild allergies to gluten can be a factor in IBS, Factor-V Leiden penetrance, clotting abnormalities, HRQOL issues. Wheat is one of the most common allergens found in rheumatoid arthritis. Like coeliac disease there is a large cohort of underdiagnosed allergies. Some of the wheat allergies are secondary to enteropathy. None the less gluten allergies are not a rare fraction of gluten sensitivity. Food allergies to wheat often become apparent only when some underlying stressor is involved. For example excessive exercise after eating, damage to the GI done by aspirin or NSAIDs. A large percentage of NSAID sensitivity, not an allergy to the drug, but the introduction of food allergens into the blood stream. Wheat and crustaceans allergies are two main triggers for anaphylaxis/urticarias that are caused by exercise/aspirin induction.

Idiopathic gluten-sensitivity. gluten-sensitive neuropathies without a clear cause are on the rise. The diagnostic criteria is in question. The proponents of this class of gluten sensitivity place the incidence at about 10 per million, whereas the critics place the incidence below 1 per million individuals. This form of gluten-sensitivity is very rare.

—Preceding unsigned comment added by Pdeitiker (talk • contribs) 14:14, June 17, 2008

Pdeitiker, please sign your talk page entries by entering four tildes ( ~~~~ ) after your posts, and please follow talk page guidelines (WP:TALK, WP:TP) for threading and responding to posts. This talk page is a dog's dinner and hard to parse. SandyGeorgia (Talk) 14:29, 17 June 2008 (UTC)

SandyGeorgia, please use critiques that make sense "WP:NOT paper" is of little value as a critique, neither is the colloquillism "dog's dinner". Your alteration on the main page "WP:MOS" (Quite large) did not indicate what change you were referring to.Pdeitiker (talk) 16:10, 17 June 2008 (UTC)

As a matter of fact, my edit summary specifically referenced the exact paragraph at MoS I was referring to. SandyGeorgia (Talk) 16:33, 17 June 2008 (UTC)

And so what did that have to do with removal of an "s" from factors? That "&nbsp" added was an edit of content made by someone else. The "edit summary" to my edit made no sense to me. Seems to me trivial spelling edits don't need a summary of this type, even so, tell the person on their talk page.Pdeitiker (talk) 17:06, 17 June 2008 (UTC)

Edit summaries are not to your edits; the general message on this page is that featured articles must conform to WP:MOS, of which WP:NBSP is one part. SandyGeorgia (Talk) 14:05, 18 June 2008 (UTC)

If it takes 20 minutes to figure out what you changed and why, the lesson you wanted people to learn gets kind-of lost. That is kind of a neat gadget to use, and thanks for posting it. Think about ways of getting your point to work.Pdeitiker (talk) 17:04, 18 June 2008 (UTC)

[edit] Changes to diet section

It appears that this change is introducing primary sources based on small samples. (It also uses different citation formatting which will need to be fixed per 2c if the changes remain.) SandyGeorgia (Talk) 14:05, 18 June 2008 (UTC)

I don't really object to the studies in question because the recent clinical reviews don't discuss QOL, and it is still of relevance even to the casual reader. But I think the subject of QOL has now been addressed and no further modifications are needed. I have fixed the citations, which contained some errors. JFW | T@lk 15:05, 18 June 2008 (UTC)

Thanks, JFW; hate to see an FA deteriorate, and it's important to stay on top of the little MoS errors before they snowball. SandyGeorgia (Talk) 15:06, 18 June 2008 (UTC)

I must say I've only recent wisened to the intricacies on WP:NBSP and the emdash. JFW | T@lk 17:34, 18 June 2008 (UTC)

The review PubMed:18344378 deals withsome of the HRQOL diseases looking at both sides. One point, the reason why study sizes are small because patients are not pooled between multiple study centers. Statistics relies on power and power of the argument can generally be assessed as a function of size of the affected population and the odds ratio. There simply aren't enough study subjects for most associated conditions in any one study center to reach a high degree of significance. The review suggests throwing out case reports and focus on double blined studies, but defends in-promptu 'gluten-free diets' and IV Ig replacement because of the disparity of some conditions. Patients can enter and exit studies at their liberty, biasing the study results. Point, it will take time to trudge through studies to see what associations will hold up.Pdeitiker (talk) 20:27, 18 June 2008 (UTC)

I mentioned this on 9 April (see Talk:Coeliac disease/Archive 3#Neurocoeliac). It is not the first study to cast doubt on a large number of possible associations. JFW | T@lk 21:00, 18 June 2008 (UTC)

And they should be casting doubt, but in a way that does not discount those studies. See picture on 1st page of review, that is what has been happening and it extends to the genetics also. That is why I don't want to add more on the Main concerning genetics. There is no balanced or objective forum where the actual evidence is available to the mass. If you get tested by a certain lab and you have DQ1 (64% of people have DQ1) they are going to treat the idiopathic gluten sensitivity issue as if 'it' and the DQ associations are settled science. Whereas this page should both expose and take NPOV. In addition, I want to see what the HapMap studies detail on subregional variation, if they find these hypermutable haplotypes are highly localized and correspond with some of the study areas, then I think the design of these studies needs to change and look at family histories and regions. This also applies to diease associated with disease studies. Genetics, diet, environment, life histories all play into these. I asked the question on that last genome-wide paper, are they hitting a locus linked to CD and T1D because T1D brings CD into the study or is it because there is independent linkage to the same locus.Pdeitiker (talk) 01:49, 19 June 2008 (UTC)

This has nothing to do with HRQOL. Quality of life is the subjective functioning as a result of illness. Neurological complications are disease entities, not just subjective experiences. JFW | T@lk 21:02, 18 June 2008 (UTC)

The review deals largely with methodology of assertion. However there are a couple of QOL issues. 1- When to institute a gluten-free diet when the only finding is anti-gliadin antibodies 2- They talk about prevelance and increase of certain conditions after diagnosis with coeliac disease. 3-The issue of low vitamin and neurological conditions associated. I pointed the review out for the same reason you mention, we can talk about associated diseases but to be neutral, we need to also point out the weaknesses of the studies. In articles dealing with depression, one paper says depression improves on GF diet, and the other paper says depression does not improve. Most of the neurological topics ~ the same.Pdeitiker (talk) 01:49, 19 June 2008 (UTC)

I don't think I understand your use of the term QOL. JFW | T@lk 05:59, 19 June 2008 (UTC)

Briefly, the new edits made to main/diet section, let us make sure that controversial science is balanced by critiques if those critiques have been made.Pdeitiker (talk) 16:21, 19 June 2008 (UTC)

What has that got to do with QOL? The new edits to the diet section reflect current professional standards, which are not displaced by the "critiques" you are citing. They have to do with disease control, not with quality of life as a dedicated indicator. I will not be able to respond sensibly if you cannot clarify why this should be a QOL issue rather than anything else. Again: in medicine QOL is a separate outcome measure, distinct from markers of disease progression or resolution. JFW | T@lk 17:31, 19 June 2008 (UTC)

[edit] Prolamin section

(since the changes have been refined to a final form I am refactoring my comments on this material to shorten the material, most of the material cropped is written by myself and so I have good faith I can represent thoughts carefully.)

Referring to the iconic review: ¹ "Recent advances in coeliac disease". doi:10.1136/gut.2005.075119

Referring to #1 and discussing the T-cell 'multi'site, "33mer"

"Interestingly, the fact that many gliadin peptides possess bulky hydrophobic amino acids followed by proline blocks the activity of intestinal peptidases such as pepsin and chymotrypsin. Thus gluten peptides able to stimulate T cells (such as a recently described 33mer sequence) are resistant to degradation by all gastric, pancreatic, and intestinal brush border membrane proteases in the human intestine."¹

Referring to #2 and discussing the innate "19mer"

"Several recent reports have suggested that one of the first events in coeliac disease pathogenesis may be a direct effect of certain wheat peptides, distinct from those recognised by T cells, on the intestinal epithelium. One such peptide, wheat A-gliadin p31-43 (LGQQQPFPPQQPY) or p31-49 induces changes associated with coeliac disease on intraduodenal administration, and in vitro in biopsy based studies."¹

Referring to #3 and discussing the factors involved in increased permeability and Zonulin release.

"Direct effects of gliadin on enterocytes may also increase intestinal permeability through release of zonulin and effects on intracellular tight junctions."¹

Pdeitiker (talk) 19:21, 19 June 2008 (UTC)

[edit] Use of the word gluten

Concerning a recent edit: " Gluten-free products are usually more expensive and harder to find than common gluten-containing foods." This somewhat reflects modern standards of cooking in which starting ingredients or whole meals are prepared and packaged. The basic starting ingredients for most gluten-free products are cheap. Apples, oranges, and dried beans and corn are always gluten free. The QOL issue is the added time coeliacs who want a healthy lifestyle on a modest budget will spend preparing food. 2nd issue Gluten-free is defined, gluten-containing has 3 different possible definitions.Pdeitiker (talk) 20:08, 20 June 2008 (UTC)

You are again using the term QOL in a totally unrelated context. Could you please explain what you mean when you refer to this elusive concept? JFW | T@lk 22:39, 21 June 2008 (UTC)

I did not use HRQOL in this instance. I think the section can be cleaned up and a little more objective. One can consider that a Lacodan Mayan has no loss of QOL or greater expense on a GF diet for food given they are not westernized and there are no indigeonous cultivars of Triticeae. Whereas those children in refuge camps that suddenly show up with CD after getting international food handouts, of course the alternative is also not pleasant. To stay on the point, QOL in this instance is this instance is a matter of convenience, for example in most areas of the US gluten free choices for dining out are limited, and require substantial education and support, some people, and I have heard this from a number, just don't go out, another QOL issue. These are not necessarily more expensive. However trying to substitute old wheat-containing diet with an exactly comparable GF diet is expensive and difficult, and, for instance, there is no comparable substitute for bread. There are other breads, for example corn tortillas, and they are in fact cheaper and healthier than most breads, the sacrifice is in the quality of taste one expects, so that is another QOL issue. Many articles have discussed this issue, and I will reference these tomorrow, adults in particular are accustomed to a certain food culture, and a GF-diet and dining-out issues can result in depression and other QOL issues.Pdeitiker (talk) 03:10, 23 June 2008 (UTC)

Remember that Featured articles need to have a SUMMARY style. Lots of stuff on a gluten-free diet and lifestyle should go in the gluten-free diet page, and if necessary a gluten-free diet and lifestyle page. ImpIn | (t - c) 03:58, 23 June 2008 (UTC)

The gluten-free page is a mess.Pdeitiker (talk) 17:34, 23 June 2008 (UTC)

[edit] Adding a mention of gluten sensitivity to the lead

SandyGeorgia just reverted my addition to the lead (diff). LEAD states that the lead "should establish context, summarize the most important points, explain why the subject is interesting or notable, and briefly describe its notable controversies". Gluten sensitivity is important context. Let's hear what other people have to say. It seems SandyGeorgia opposes this addition. I want to hear JFD, TimVickers' and Ptdeikers' position -- as well as anyone else. Please concisely reply. If we can't agree to put it in, I'll put up a RFC. That article has too much important information, and it is too easy to miss currently in the template. ImpIn | (t - c) 04:08, 23 June 2008 (UTC)

None of my major sources for this article refers to the concept "gluten sensitivity". What is the reason that you think it should be given this level of prominence? I think the onus is on you to demonstrate this, not vice versa.

I am a bit concerned about your choice of words above: "If we can't agree to put it in." Does that mean you will yield to consensus, or will you fight it all the way? Because I can predict the responses from Tim and Phil (and Sandy for that matter). JFW | T@lk 05:29, 23 June 2008 (UTC)

Pubmed for "gluten sensitivity"[All Fields] gives 190 citations. This is piddly compared to 12413 for "celiac disease". Most of the citations yielded by "gluten sensitivity" are about GSE anyway and not about this elusive concept of "hmm my patient is ill and has anti-gliadin antibodies - interesting... never mind that they don't respond to a diet".JFW | T@lk 05:48, 23 June 2008 (UTC)

I think Full text at PMC: 1737870 is an example of the protagonists of this concept, which is by no means accepted in the coeliac disease research community and cannot possibly be discussed in the lead with such a degree of prominence. JFW | T@lk 05:48, 23 June 2008 (UTC)

Well put, but also the third party testing lab that finds idiopathic disease under every DQ1 type, never mind that excluding all DQ2 and DQ8s from the populatin DQ1 represents about 90% of what is left.Pdeitiker (talk) 06:23, 23 June 2008 (UTC)

I was practically kicked into creating that page, it was by no means a great joy to create. Let me put it like this, biochemist like myself like to have pretty categories to place things into. Gluten sensitivity is not one of those categories. Although the page has evolved with new information, and it serves auxiliary function. Coeliac disease has a set of diagnostic responses that are not shared by the other two diseases (if you can count the GS idiopathic neuropathies as a disease). The membrane permeability issues appears to be independent between EIA and CD (although many CD have wheat induced urticaria and aspirin sensitivities). Let us wait on the issue of creating a universal umbrella for coeliac disease in gluten sensitivity when many papers still treat GS as suspect GSE without a diagnosis (such as in newly diagnosed derm. herp.). The difference, is that a person who finds the GS page first may enter as a result of some third party testing lab that finds GS under tea leaves, whereas if they enter CD they might have been told they have gluten sensitivity as a result of dermatitis herpetiformis. Probably my opinion is going to change with more work on innate immunity (and a review that makes everyone happy).

By the way, I would classify gluten sensitivity outside of coeliac disease a notable controversy. No-one contests that CD exists, but there is a contest over idiopathic sensitivity and whether some aspects of these allergies are allergies or more deeply rooted intolerances. In terms of linking to that page, let me just say, the title is designed to pickup direct from the internet as to route people toward the CD page, not away. JFW added the linking box to the Main.Pdeitiker (talk) 06:14, 23 June 2008 (UTC)

I would like to see more linkout to the oat controversy on that page. I think I have done a really good job of defining the controversy. :^).Pdeitiker (talk) 06:14, 23 June 2008 (UTC)

So, Phil, what is your opinion on linking gluten sensitivity from the lead? This discussion is not about DQ1 and third party testing. You seem to suggest that the page by that name is simply an overflow because you have been stopped from using the coeliac disease page to put all that content. JFW | T@lk 06:31, 23 June 2008 (UTC)

At this point in time it is unnecessary. The issue of adding to this page needs a developed process of creation and discussion. That process may also need background, as the genetics section did. All of the new issues are increasingly complicated.Pdeitiker (talk) 14:26, 23 June 2008 (UTC)

Since it is such a big deal, I'll drop it. In the future it may have to be added. Gluten sensitivity is mentioned in this (pdf) overview of current research from the Celiac Disease Foundation (in addition, the intestinal biopsy debate is mentioned). Worth looking at. ImpIn | (t - c) 06:50, 23 June 2008 (UTC)

Fasano says that the phenomenon of "gluten sensitivity sans coeliac" is awaiting confirmation. That is actually perfect evidence to support my skepticism. Thanks. JFW | T@lk 11:36, 23 June 2008 (UTC)

Right, but we can add information that underlies the changing concept of prolamins without embracing a holo-concept of gluten sensitivity. Gluten-sensitivity is like 'slims' disease or god, it exists because people believe 'it exists' (in fact that is the Mosaic definition of god), in that light gluten-sensitivity will likely grow in acceptance. OTOH, people are at a richly designed site, this page. Some these people are self-diagnosed which really means they are gluten-sensitive. As I told ImpInf, if he wants to create a self-diagnosis section he can add it to the GS page and we can see what becomes of it. I was looking for a paper but I could not find it, it claimed something of 120 people who refused typing but were placed on a GF diet because of symptoms after eating wheat about half on gluten challenge had GSE the other half? Why they did not test for other sensitivity, wheat allergy?Pdeitiker (talk) 14:27, 23 June 2008 (UTC)

That is the problem in the way people think, you can't have a result unless biopsy, fine, but then if the result is negative what are you as a researcher going to do. Another paper showed that post-treatment diarrhoea in CD ussually has an explanation that physicians simply do not investigate the symptoms. I know 2 people who thought they might be CD one had the gene the other did not both ended up having gluten allergy, one had a very severe allergy and she had to pay for the testing out of pocket. If the physicians did proper testing 'gluten sensitivity' would not exist.Pdeitiker (talk) 14:26, 23 June 2008 (UTC)

[edit] Reliable sources

Please confine edits to reliable sources; Celiac.com is not an adequate source for any article, and certainly not for a featured article.[2] I will make the MoS corrections, but since this text is not based on a reliable source, it will still need to be corrected. Please take care not to cause deterioration to a featured article but introducing non-reliable sources and MoS errors. Thanks, SandyGeorgia (Talk) 04:55, 23 June 2008 (UTC)

Since it was used as a source already, I assumed that it was fine (ref 72). I disagree with you that it's unreliable for these claims -- these are uncontroversial, non-scientific statements. Should I post a notice to RS/N? Do we have to go to dispute resolution for this as well? ImpIn | (t - c) 05:02, 23 June 2008 (UTC)

That type of text should be sourceable to a reliable source. SandyGeorgia (Talk) 05:10, 23 June 2008 (UTC) (Perhaps you can see the difference between citing text relating to an Italian organization and text related to FDA regulation in the USA in terms of the sources expected ??) SandyGeorgia (Talk) 05:13, 23 June 2008 (UTC)

You write that as if you expect me to see a difference. :p I don't. Both are standard reporting -- can you please elaborate on the difference? If we can trust Celiac.com (run by a US citizen) to report on some Italian organization correctly, why should we not trust them to report on the standards in the US correctly? If you want to source to the FDA so badly, here is the most recent link. How about the other places where Celiac.com is used? And do I read you correctly in implying that you are OK with ref 72? ImpIn | (t - c) 05:25, 23 June 2008 (UTC)

Sandy, if there is a problem with the regulation of the concept "gluten free", then FDA and Celiac.com sources may be notable. Clearly, this label is not as strictly regulated as one would wish. To compare, in the USA a product can only be labeled "kosher" if it has been thus certified by a rabbinic authority. Working in the UK I am not very familiar with this debate, but it seems to me that patient organisations are pressurising the FDA to tighten up on gluten free labelling.

Obviously, if this can be sourced to more reliable print sources, or to peer-reviewed journals, we'd all be happier. JFW | T@lk 05:33, 23 June 2008 (UTC)

On reflection, I notice that celiac.com is nothing more than a glorified blog. Could there be better sources on celiac.ORG, the site of the Celiac Disease Foundation? JFW | T@lk 06:08, 23 June 2008 (UTC)

It's a bit much to say that it is a glorified blog -- its a clearinghouse for information on CD, including a store for gluten-free food. The claims that celiac.com are making are really uncontroversial: 1) that the GF label is not regulated in the US (true -- this can be replaced by FDA link), and 2) that most "gluten-free" products contain traces of gluten -- accepted in the Codex standards, widely known, obvious. Partly I linked to celiac.com for its decent explanation of how the standards work, but if we can find a better, recent overview, that would be great. The literature that I've glanced at seems to skip over a discussion on this.[unsigned message]