CELIAC DISEASE 179
National Research Council Canada, Genome Can-
ada/Genome Prairie, and Canada Saskatchewan
Agri-Food Innovation Fund are gratefully acknowl-
edged for supporting research in our laboratories.
See also: Cereals: Chemistry of Nonstarch Polysaccha-
rides. Grains Other than Cereals, Nonstarch Polysac-
charides. Protein Synthesis and Deposition. Starch:
Uses of Native starch; Analysis of Quality; Chemistry; Mod-
ification; Synthesis. Lipid Chemistry.
Further Reading
Bressani R and Elias LG (1988) Seed quality and
nutritional goals in pea, lentil, faba bean and chickpea
breeding. In: Summerfieldf RJ (ed.) World Crops: Cool
Season Food Legumes, pp. 382!411. Dordrecht, The
Netherlands: Kluwer Academic.
Buchanan BB, Gruissem W, and Jones RL (2000)
Biochemistry and Molecular Biology of Plants. Rock-
ville, MD: American Society of Plant Physiologists.
Chibbar RN and Båga M (2003) Genetic modification of
primary metabolism ! carbohydrates. In: Thomas B,
Murphy DJ, and Murray BJ (eds.) Encyclopedia of
Applied Plant Sciences, pp. 449!459. Oxford, UK:
Elsevier.
Hedley CL (2001) Carbohydrates in Grain Legume Seeds:
Improving Nutritional Quality and Agronomic Char-
acteristics. Wallingford: CABI Publishing.
Hrmova M and Fincher GB (2001) Structure-function
relationships of b-D-glucan endo- and exohydrolases
from higher plants. Plant Molecular Biology, 47:
73!91.
CELIAC DISEASE
H Wieser, German Research Center of Food
Chemistry, Garching, Germany
ª 2004, Elsevier Ltd. All Rights Reserved.
Introduction
Celiac (coeliac) disease (CD) is a permanent intestinal
intolerance to dietary wheat, rye, and barley proteins
(gluten) that produces mucosal lesions and nutrient
malabsorption in genetically susceptible individuals.
The current essential therapy is a strict lifelong
Keller F and Pharr DM (1996) Metabolism of carbohy-
drates in sinks and sources: galactosyl-sucrose oligo-
saccharides. In: Zamski E and Schaffer AA (eds.)
Photoassimilate Distribution in Plants and Crops !
Source-Sink Relationships, pp. 157!183. New York:
Marcel Dekker.
Kruger NJ (1997) Carbohydrate synthesis and degradation.
In: Dennis DT, Turpin DH, Lefebvre DD, and Layzell
DB (eds.) Plant Metabolism, pp. 83!104. Harlow,
Essex, England: Addison Wesley Longman Limited.
Sathe SK, Deshpande SS, and Salunke DK (1984) Dry
beans of Phaseolus. A review: Part 2. Chemical
composition: carbohydrates, fiber, minerals, vitamins,
and lipids. CRC Critical Reviews in Food Science and
Nutrition 21: 41!93.
Shelton DR and Lee WJ (2000) Cereal carbohydrates.
In: Kulp K and Ponte JG, Jr (eds.) Handbook of Cereal
Science and Technology, 2nd edn., pp. 385!415. New
York: Marcel Dekker.
Relevant Websites
http://www.chem.qmul.ac.uk ! International Union
of Pure and Applied Chemistry and International
Union of Biochemistry and Molecular Biology;
IUPAC-IUBMB Joint Commission on Biochemical
Nomenclature (JCBN) ! Nomenclature of
Carbohydrates.
http://www.fao.org ! Includes classification and
chemistry of carbohydrates, carbohydrate meta-
bolism in fish, factors affecting it and energy
transformation.
withdrawal of gluten from the diet. The prevalence
of CD was underestimated for a long time; with the
development of sensitive serological tests, it is now
becoming clear that CD is one of the most frequent
food intolerances in many parts of the world. An
overview of extensive research on CD is provided.
Definition
CD also known as celiac sprue and gluten-sensitive
enteropathy, may be defined as an inflammatory dis-
ease of the upper small intestine (duodenum, jejunum)
180 CELIAC DISEASE
in genetically susceptible individuals. CD is a perma-
nent food intolerance induced by ingestion of storage
proteins (gluten) from certain cereals (wheat, rye, bar-
ley) that causes damage of the enterocytes and, as
a consequence, malabsorption of important nutriti-
ents. CD patients develop a flat jejunal mucosa
with the absence of normal villi, a cellular infiltrate
of the lamina propria and an increase of the number of
intraepithelial lymphocytes. The mucosa improves
morphologically on treatment with a gluten-free
diet and relapses when gluten is reintroduced. Imme-
diate symptoms of CD frequently include diarrhea,
cramps, and pale and bulky stools. Therapeutically,
lifelong gluten-free diet is necessary.
Historical Review
CD was already noted by the Roman physician Are-
taeus the Cappadocien as early as the second century
AD, describing that ‘‘if diarrhea does not proceed from
a slight cause of only one or two days duration and if,
in addition, the general system be debilitated by at-
rophy of the body, the celiac sprue of chronic nature is
formed.’’ However, it was not until 1888 that Samuel
Gee described the classical account of CD features. He
recognized that ‘‘if the patient can be cured at all it
must be by means of the diet.’’ Thereupon the dietary
treatment of CD was continued more or less success-
fully. For example, all sources of carbohydrates such
as bread, cereals, and potatoes were excluded or
a banana diet was recommended. Such extreme die-
tary therapy was then used extensively for many
years.
In 1950, WK Dicke, a Dutch pediatrician, observed
a decline in CD in Holland during the grain-deprived
years of the Second World War. A clear association
between CD and the ingestion of wheat and, later on,
of rye and barley, was established. Fractionation of
wheat flour and testing led to the conclusion that
gluten was toxic, whereas starch and the water-
soluble albumins were not. Since that time,
a ‘‘gluten-free diet’’ was the conventional treatment
of CD, which excluded products containing wheat,
rye, and barley only excepting pure starches produced
from these cereals. The celiac toxicity of oats has been
judged controversially up to this day.
Symptoms and Pathology
A range of symptoms may be associated with CD and
these can be divided into intestinal features and those
caused by malabsorption (e.g., deficiency of vitamins
and minerals). In infants, classical symptoms appear
after weaning and introduction of cereals into the
diet: diarrhea, abdominal distension, failure to thrive,
vomiting, muscle wasting, and apathy. Older children
tend to have more varied symptoms, besides diarrhea
or constipation features such as anemia, loss of ap-
petite, and short stature may be predominant. Diar-
rhea is the main presenting feature of adults, in some
patients anemia, osteoporosis, abdominal pain, loss
of weight, and weakness may be found. A minor num-
ber of patients present psychological or psychiatric
symptoms. Frequently, the disease may be clinically
silent or masked by associated diseases like diabetes,
though the patients exhibit the full mucosa lesion.
They are discovered only when intestinal studies
are undertaken.
The small intestinal lesion of CD has a highly
characteristic morphology, but it may vary from pa-
tient to patient depending on the severity and extent of
disease. Patients show a wide variation of mucosa
appearance from a complete flat to a convoluted pat-
tern. The parameters usually assessed for the mea-
surement of intestinal mucosa are villous height,
villous width, villous height to crypt depth ratio, mu-
cosal thickness, epithelial cell height, crypt mitotic
activity, and number of intraepithelial lymphocytes.
Electron microscopy demonstrates fewer microvillous
intramembrane particles and abnormal tight junc-
tions between epithelial cells. In untreated CD, there
are raised serologic antibodies to gliadin, reticulin,
endomysium, and tissue transglutaminase (tTG).
Epidemiology and Genetics
CD is mostly a disease prevalent in Europe and those
countries to which Europeans have emigrated includ-
ing North and South America and Australia. How-
ever, CD is also known to occur in many other parts
of the world. In former times, CD was considered
a comparatively uncommon disorder with prevalence
rates of 1 in 2000!1000. Several recent studies using
serologic screening followed by small intestinal bi-
opsy have shown a much higher prevalence, and it
is now estimated that CD may affect 1 in 300!100
individuals. The iceberg is a common model to de-
scribe the epidemiology of CD. The tip of the iceberg
is formed by patients who have been diagnosed by
conducting a biopsy demonstrating a flat mucosa.
Below the waterline, there is a big group of undiag-
nosed patients with a flat mucosa, but with no or
weak symptoms (silent CD). Just at the bottom of
the iceberg there is a small section of patients with
a normal mucosa, but with the genetic predisposition
and increased levels of celiac-specific antibodies.
These subjects may develop clinically overt CD
later in life (potential CD).

The occurrence among first-degree relatives of
CD patients has been reported to be fairly strongly
(10!15% prevalence). Concordance between dizy-
gotic twins has been found to be in a range of
11!20% and that between monozygotic twins
70!86%. CD can occur at any age, but in adults, the
peak incidence is in the fifth decade. Females are more
commonly affected than males, the ratio has been
suggested to be 2:1.
CD is associated with histocompatibility complex
class II alleles HLA-DQ2 and HLA-DQ8. HLA-DQ2
was found in 98% of celiac patients from northern
and central Europe. However, 25% of the healthy
population carry DQ2 and will never develop CD.
Thus, genetic factors alone do not explain the
development of CD and additional factors such as
infection agents and hormonal status may be in-
volved. In southern Europe and Israel, DQ2 is also
the major susceptibility genotype (92%), there is
another small section who carry DQ8. The only
nonHLA region to which association with CD has
been convincingly shown until now is the CTLA-4/
CD28 region on chromosome 2q33.
Pathogenesis
The earliest theory on the pathogenesis of CD was
based on the missing peptidase hypothesis. The
basic defect was considered to be a deficiency of an
enzyme in the small intestine which is required for the
digestion of celiac toxic proteins. This theory was
supported by studies of the celiac-active peptide frac-
tion 9 isolated from an enzymatic digest of gluten.
This fraction was only partially digested by homog-
enates of remission celiac mucosa, whereas it was
completely digested by corresponding homogenates
from normal people. Other authors, however, have
shown that peptidase activities are normal in the mu-
cosa of CD patients on a gluten-free diet. Neverthe-
less, the enzymatic hypothesis cannot be completely
ruled out, because enzymatic activities within the
enterocytes have not been studied sufficiently until
now. Another theory was based on a nonimmuno-
mediated lectin-like effect of celiac toxic proteins
due to binding to glycoproteins on intestinal epithelial
cells of CD patients. Carbohydrate side chains of
toxic proteins were postulated to be important in ac-
tivating CD. However, there was little evidence to
support this because A-gliadin, a group of aggregative
a-gliadins known to be celiac toxic, lacks such carbo-
hydrate side chains. Partial sequence homology
between an adenovirus E1B protein and a-type glia-
dins led to the proposal that human adenovirus type
12 might be an environmental factor involved in the
pathogenesis of CD.
CELIAC DISEASE 181
The currently accepted theory of pathogenesis is
based on a primary immune response to gluten pro-
teins as antigens and to tTG which has been identified
as the autoantigen recognized by the endomysial
antibodies. The antigens are regarded not to be the
intact gluten proteins, but certain peptides which are
formed from the proteins as a result of exposure to
proteolytic enzymes of the gastrointestinal tract. The
peptides are bound to the intestinal mucosa, then pass
through the enterocytes by means of endo- and exo-
cytosis and come into contact with the macrophages
and antigen-presenting cells of the lamina propria.
There are indications that the process is induced by
a hyperimmune response in individuals with the his-
tocompatibility antigens DQ2 and DQ8. The gluten
peptides are bound specifically to these HLA mole-
cules, processed, e.g., deamidated by tTG and pre-
sented to the T cell receptors of gluten-sensitive
CD4 helper cells (Figure 1). The T cells then provide
help for the production of antibodies to gluten pro-
teins and autoantibodies to tissue transglutaminase.
Simultaenously, the stimulation of T cells leads to the
secretion of pro-inflammatory T helper (Th-1) cyto-
kines, in particular g-interferon and nitric oxide which
produces premature senescence of small intestinal
enterocytes, shedding of these cells and, in turn, the
observed small intestinal enteropathy.
Associated Diseases
Dermatitis herpetiformis, a skin disorder, is associ-
ated with CD, because some degree of gluten-sensi-
tive enteropathy is common to both conditions. It
appears as patches of itchy red papules and blisters
on the extensor surface and pressure areas; healing up
results in pigmentation. Histologically, there is infil-
tration of the dermal papillae with inflammatory
cells. The histology of the small intestine is similar
to that of CD, but the abnormalities tend to be milder
and more patchy. In many cases, a gluten-free diet
results in a significant improvement. Recent screening
studies have shown an increased prevalence of CD in
autoimmune disorder such as type 1 diabetes, thyroid
disease, primary biliary cirrhosis, and Sjögren syn-
drome. Moreover, IgA deficiency, chronic fibrosin
alveolitis, and other interstitial lung diseases, con-
comitant distal ulcerative colitis have been reported
in association with CD. In other instances, there are
unexpected associations such as epilepsy and various
undefined neurological disorders. A small number
of patients with CD have exhibited symptoms of
various psychiatric disorders, e.g., schizophrenia. A
lymphoma of the small intestine is the classical ma-
lignancy associated with CD. The prevalence of car-
cinoma of the small intestine, esophagus, or pharynx
182 CELIAC DISEASE

Crypt hyperplasia
Villous atrophy Permeability increase Dietary gliadin
Mucosal hypertrophy

Gliadin cross-linking and

deamidation by tTG
IgA IgA IgA
Th2 !-gliadin !-tTG !-tTG-
cross-links

Tcyt T
T
B
Matrix T
breakdown and Plasma
B
remodeling T
T cell
MΦ
MMP-1 B
DC
MMP-3
TT
KGF B
tTG HLA-DQ2 TCR
Th1 gliadin
CD4+ tTG
TNF-! deamidated gliadin
gliadin-tTG complex

Figure 1 Immune response in the gut-associated lymphoid tissue and destruction of enterocytes in the pathogenesis of CD (B ¼ B
cell, CD4 ¼ helper T cell, DC ¼ dentritic cell, HLA ¼ human leucocyte antigen, Ig ¼ immuno-globulin, KGF ¼ keratinocyte growth
factor, M ¼ macrophage, T ¼ T cell, TCR ¼ T cell receptor, TNF ¼ tumor necrosis factor, tTG ¼ tissue transglutaminase). (Courtesy
of D Schuppan, Erlangen, Germany (previously unpublished).)

also increases with CD. It has been reported that
a strict gluten-free diet helps safeguard against
these malignancies.
Diagnosis
Most important for the diagnosis of CD was the in-
troduction of small intestinal biopsies in 1960. Since
that time mucosal biopsy is regarded as the golden
standard for the firm diagnosis of CD. The histolog-
ical examination of biopsy specimens demonstrates
a flat mucosa with the absence of normal intestinal
villi, a cellular infiltrate of the lamina propria, and an
increase in the number of intraepithelial lymphocytes.
The European Society for Pediatric Gastroenterology
and Nutrition (ESPGAN) recommended three intes-
tinal biopsies in 1970. One should be performed at the
time of presentation, another after the patient has
been on a gluten-free diet demonstrating improve-
ment and the final biopsy after the patient has been
rechallenged with gluten, when villous atrophy is
expected to have recurred. The question of whether
three biopsies and supervised gluten rechallenge
are necessary has been a matter of debate. Recently
ESPGAN has suggested that it is not mandatory to
proceed to a gluten challenge, if a gluten-free diet has
produced a good improvement in symptoms and in
the morphology of the biopsy specimen. Noninvasive
screening tests would be of considerable aid in diag-
nosis, but cannot replace histology. In untreated CD,
there are enhanced antibodies to gliadins, reticulins,
endomysium, and tTG (Figure 1). IgA antigliadin
antibodies have a sensitivity of "80!90% and
a specificity "85!95%. IgG antigliadin antibodies
are less sensitive and specific. Until recently the
determination of IgA antiendomysial antibodies
was the most important test in the diagnosis of CD
reading sensitivity and specificity "97%. The combi-
nation of antigliadin and antiendomysial antibodies
has positive and negative predictive values ap-
proaching 100%. The recent demonstration that
the antigen for endomysium is tTG has allowed the
development of an enzyme-linked immuno-sorbent
assay (ELISA) for both IgG and IgA tTG. They
are similar in sensitivity and specificity like the
endomysial antibody test, but they are cheaper and
their results are much easier to reproduce.
Therapy
After a diagnosis of CD has been established, perma-
nent withdrawal of gluten from the diet is the current
essential treatment. Gluten-free diet involves avoiding
products containing wheat, rye, and barley. Starches

of these cereals are permitted, when the nitrogen con-
tent does not exceed 0.05% (Codex Alimentarius
Standard 1981) or the gluten level is lower than
200 mg per kg (Draft Revised Codex Standard
2000). The daily intake of gluten should not exceed
20 mg. The toxicity of oats has been discussed con-
troversially. Recent studies have, however, provided
strong evidence that oats do not damage the mucosa
of CD patients. Since small amounts of gluten are
hidden in many foods, dietary counseling is absolutely
necessary. In most countries celiac societies are an
invaluable help in providing dietary guidelines and
food lists. Keeping a strict gluten-free diet most
patients show a rapid clinical response with impro-
vement of symptoms within weeks. Histological im-
provement is slower and complete recovery can take
months or years. The prognosis for patients who are
correctly treated is excellent. Failure to implement
a strict diet may result in continuing symptoms and
in the two major complications of osteoporosis and
malignancy.
CD patients consume gluten-free food from two
different categories. First, they are allowed to eat
a wide range of common products such as meat,
fish, milk, fruits, and vegetables. In the case of com-
posite foods, however, it is difficult to recognize
whether they are gluten free or not. An informative
labeling of gluten as an ‘‘allergen’’ is currently
discussed in the framework of Codex Alimentarius
and in the European Union. Second, patients con-
sume dietetic food that is gluten free according to the
Codex Alimentarius Standard. The new standard
draft proposes a gluten level of 20 mg per kg dry mass
for naturally gluten-free food and 200 mg per kg for
food rendered gluten free such as wheat starch. For
gluten analysis, extraction with 60% ethanol and an
immuno-chemical method for quantitative determi-
nation (ELISA with mono- or polyclonal antibodies)
are recommended. Dietetic gluten-free foods are
mostly substitutes of products usually containing
wheat, rye, and barley such as bread, other baked
products, pasta, and beer. Common basic materials
used for these products are flours from maize, sor-
ghum, rice, buckwheat, or chestnut, and common
thickening agents are locust bean gum or guaran gum.
Toxicity Testing
Most investigators would agree that in vivo testing is
the ‘‘gold standard’’ for assessing CD toxicity of pro-
teins or peptides. Early workers established toxicity
in a series of feeding tests based on the production of
symptoms such as steatorrhea or on tests such as mal-
absorption of fat or xylose. However, an important
impediment was that CD patients differed widely in
CELIAC DISEASE 183
their sensitivity to gluten and consequently, the opti-
mal amount of gluten equivalent used to challenge
patients and the duration of challenge were uncertain.
In any case, 10!100 g of gluten equivalent were nec-
essary for the testing of each patient and such large
amounts were the most crucial limiting factor for the
feeding tests of purified proteins or peptides.
By direct instillation into the small intestine fol-
lowed by biopsy, the required amounts could be
reduced to 1 g equivalent of gluten. Some of the his-
tological changes of the mucosa have been noted as
early as 2 h from the beginning of instillation. Simi-
larly, mucosa of CD patients is sensitized to gluten
and offers a more convenient approach for investiga-
tive and diagnostic purposes. One to two hours after
challenge with 2 g gluten equivalent, mucosa showed
significant swelling of the lamina propria, a rapid fall
in most cells, and a marked rise of intraepithelial lym-
phocytes. Because in vivo tests require relative large
quantities of substances and only a limited number of
test patients are available, a series of in vitro tests has
been developed. The organ culture of human small
intestine, which requires only milligram equivalents
of gluten, has been proposed as providing the most
reliable in vitro approach. The intestinal tissue from
patients with active CD is removed as a part of the
diagnostic procedure and incubated in a culture
medium. The tissue shows improvement of enzyme
activity and morphology in the medium alone, but not
in the presence of CD toxic substances. Apart from
human material tissue cultures with fetal rat and
chicken intestine have been used. Assays based on
the stimulation of peripheral blood lymphocytes,
the production of the leukocyte-migration inhibi-
tion factor or macrophage proagulant activity, the
agglutination of leukemia K562 cells, and the disrup-
tion of rat liver lysosomes have been applied for
screening tests. However, in vivo testing ultimately
will be necessary to evaluate conclusions on in vitro
testing.
Toxicity of Cereal Proteins
The relationship between CD and the ingestion of
wheat flour was established in 1950. Soon after,
a series of investigations led to the conclusion that
rye and barley were also harmful, whereas maize,
rice, buckwheat, and potatoes were not. There has
been disagreement about the toxicity of oats; the rea-
son for that could have been that commercial oat flour
is frequently contaminated with small amounts of
wheat, rye, or barley. Recent studies, however, indi-
cated that pure oats do not activate CD. Accordingly,
CD is closely related to the taxonomy of cereals: only
species found in the tribe Triticeae within the grass
184 CELIAC DISEASE
family Poaceae are likely to exacerbate CD. All wheat
species besides bread wheat such as durum wheat,
spelt, emmer, einkorn, and kamut has been proposed
to be toxic for CD patients.
Immediately after wheat was established as the CD
activating cereal, fractionation of the flour and in vivo
testing led to the conclusion that gluten is toxic,
whereas starch and albumins are not. Gluten is the
rubbery protein mass that remains when wheat dough
is washed with water to remove starch granules and
other soluble constituents. By its cohesive viscoelastic
properties gluten to a large extent determines the
unique baking quality of wheat. Gluten proteins
can be divided according to their solubility in aqueous
alcohols into the soluble gliadins and the insoluble
glutenins. Toxicity tests indicated that the gliadin
fraction was the most toxic factor, whereas the effect
of the glutenin fraction was described either nontoxic,
weakly toxic, or as toxic as gliadins, but on a very
inadequate evidence. The reason for this disagreement
could be that glutenin preparations isolated from
wheat flour or gluten have been differently contami-
nated by gliadin components covalently bound to
the glutenin aggregates.
Flour protein fractions of rye and barley have not
been tested for celiac toxicity until now, but equiva-
lent to the gliadin fraction of wheat, the correspond-
ing prolamin fractions of rye (secalins) and barley
(hordeins) were associated with CD. Although the
prolamin fractions of cereals are crude mixtures of
different proteins, their amino acid compositions
show a close relationship to both taxonomy and celiac
toxicity (Table 1). Toxic gliadin, secalin, and hordein
fractions are characterized by the highest contents of
glutamine (35!37 mol.%) and proline (17!23%).
Both amino acids have been considered to be impor-
tant for CD toxicity. The prolamins of rice, millet, and
maize are lower in glutamine and proline, but rich in
alanine (9!14 mol.%) and leucine (12!19 mol.%).
Oats are in a medium position, the glutamine content
being similar to the Triticeae prolamins and the values
of proline and leucine in agreement with those of
other species.
Table 1 Partial amino acid composition (mol.%) of prolamins
Wheat (gliadin) Rye (secalin) Barley (hordein)
Glx 37 35 35
Pro 17 18 23
Leu 7 6 6 11
Ala 3 3 2 6
Met 1 1 1 2
Lys 1 1 1 1
Trp 0 0 1 0
Among the prolamin fractions, only gliadin from
wheat has been investigated in detail. The digestion
with pepsin and trypsin alone or followed by pancrea-
tin resulted in the retention of toxicity, and a peptide
mixture with a molecular mass less than 1000 was still
toxic. Also, the breakdown of the disulfide bonds by
oxidation or heating during the baking process did
not destroy toxicity. In consequence, the three-dimen-
sional structure of gliadin proteins is not important
for the toxic effect. The complete degradation into
free amino acids by acid hydrolysis, however, ren-
dered it harmless, as did extensive deamidation of
glutamine side chains with a limited cleavage of pep-
tide chains. Among the different gliadin types (a-, g-,
and o-gliadins), A-gliadin, a well-defined small group
of aggregable a-type gliadins, was shown first to be
toxic by instillation into small intestine followed by
biopsy. Subsequent in vivo and in vitro studies dem-
onstrated that all gliadin types produce toxic effects.
In contrast, the major protein types of the glutenin
fraction, high-molecular-weight (HMW) and low-
molecular-weight (LMW) subunits have not been
tested in vivo until now. Recent studies demonstrated
an intestinal T cell response to TG-deamidated HMW
subunits of glutenin.
Only few attempts were made to detoxify
gluten, namely by enzymatic treatment; whereas the
digestion of gluten by pepsin, trypsin, and pancreatin
resulted in the retention of toxicity, further digestion
with fresh pig intestinal mucosa rendered the prepa-
ration nontoxic. By another study, the toxic action of
gluten was eliminated by crude papain, but not after
digestion with pure papain. The crude papain used
was found to contain a deamidase which liberates
free ammonia from gluten. Recently an endopepti-
dase derived from the bacterium Flavobacterium
meningosepticum was demonstrated to cleave the
normally resistant proline-rich region of a-gliadins
corresponding to a 33 amino acid fragment. Accord-
ingly, the T cell activating properties of the peptide
was rapidly diminished by the enzyme. The authors
suggested a strategy for oral peptidase supplement
therapy for CD.
Oats (avenin) Rice (oryzin) Millet (kafirin) Corn (zein)
34 20 22 19
10 5 8 10
12 13 19
9 14 14
1 2 1
1 0 0
1 2 0

Toxicity of Peptides
Because gliadin could be partially hydrolyzed by en-
zymes without loss of toxicity, further investigations
were focused on the testing of peptides. The introduc-
tion of in vitro test systems, in particular the organ
culture test, enabled the detection of toxic compounds
in milligram and even microgram amounts. Pure pep-
tides were isolated from enzymatic digests of whole
gliadin and A-gliadin by different separation tech-
niques. A dodecapeptide corresponding to residues
75!86 of a-gliadins and isolated from a peptic tryptic
pancreatic digest of gliadin was shown to be effective
on fetal chick intestine and on rat liver lysosomes.
Organ culture tests with tissues from CD patients
revealed that peptides corresponding to the residues
1!30, 3!55, 3!24, 25!55, and 31!55 of a-gliadins
were toxic. Peptides corresponding to the resid-
ues 56!68 and 247!266, however, were inactive.
Altogether the results indicated that regions from
the N-terminal domain of a-gliadins are involved in
the pathogenesis of CD. They are characterized by
high contents of glutamine and proline, and the
tetrapeptide sequences PSQQ and QQQP common
for the toxic peptides have been considered as key
sequences for further studies. b-Turn conformations
of the peptides has been suggested to contribute to
toxicity.
Since 1987, a panel of synthetic peptides containing
sequences of gluten proteins has been tested using
in vitro and in vivo systems. In the following the re-
sults of instillation (in vivo) and organ culture tests
(in vitro) are summarized (Table 2). Five synthetic
peptides derived from a-gliadin sequences were tested
both in vivo and in vitro. Peptides a 31!43, a 31!49,
Table 2 Toxicity of synthetic gliadin peptides
Origina
a 3!21
a 31!43
a 31!49
a 31!49, A 31
a 31!49, A 36
a 31!49, A 38
a 31!49, A 39
a 31!49, A 42
a 44!55
a 56!68
a 56!75
a 202!220
a 206!217
a
Positions within A-gliadin.
b
One-letter code for amino acids.
c
OC ¼ organ culture; IN ¼ instillation; (þ) toxic in some patients; (!) negative.
CELIAC DISEASE 185
and a 44!55 were found to be toxic and peptides
a 3!21 and a 202!220 were not toxic. Peptides com-
prising alanine-substituted variants of peptide 31!49
remained toxic in some patients when residues L31
and P36 were substituted, but lost toxicity when res-
idues P38, P39, and P42 were substituted. In further in
vivo studies, peptides a 206!217 and a 56!75 were
toxic, whereas the shortened peptide a 56!68 turned
out to be inactive. Although the investigations de-
scribed were somewhat unsatisfactory with regard to
both number of tests and purity of peptides, it could be
concluded that regions of most toxic sequences of
a-gliadins occur in the repetitive N-terminal domain
and consist mainly of glutamine, proline, and aromatic
amino acids. Corresponding repetitive sequences of
g- and o-gliadins fit well into the potentially toxic
sequences of a-gliadins, whereas the repetitive
sequences of LMW and HMW subunits of glutenin
show significant differences.
Recently, a number of intestinal T cells from CD
patients have been studied in order to determine the
stimulation capacity of gluten peptides. A selection of
such peptides is presented in Table 3. Several stimu-
latory epitopes were found in a- and g-gliadins that
are mostly located in the glutamine and proline rich
N-terminal domain. With one exception (g 60!79),
the peptides were barely stimulatory in an untreated
form, but became stimulatory by deamidation after
acid-heat or tTG treatment. Studies of peptides from
the N-terminal domain of a-gliadins demonstrated
that the deamidation of a single glutamine residue
at position 65 was critical for T cell recognition.
Such negatively charged residues were proposed
to be preferred in positions 4 and 6 of the antigen
binding grove of HLA-DQ2 molecules. Modification
Sequence b Toxicity (test)c
VPVPQLQPQNPSQQQPQEQ ! (OC, IN)
LGQQQPFPPQQPY þ (OC, IN)
LGQQQPFPPQQPYPQPQPF þ (OC, IN)
AGQQQPFPPQQPYPQPQPF (þ) (OC)
LGQQQAFPPQQPYPQPQPF (þ) (OC)
LGQQQPFAPQQPYPQPQPF ! (OC)
LGQQQPFPAQQPYPQPQPF ! (OC)
LGQQQPFPPQQAYPQPQPF ! (OC)
PQPQPFPSQQPY þ (OC, IN)
LQLQPFPQPQLPY ! (IN)
LQLQPFPQPQLPYPQPQLPY þ (IN)
QQYPLGQGSFRPSQQNPQA ! (OC, IN)
LGQGSFRPSQQN þ (IN)
186 CELIAC DISEASE

Table 3 Amino acid sequences of selected peptides tested for intestinal T cell stimulation of CD patients

Origin (positions) Sequencea Activity

g5 (60!79) LQPQQPFPQQPQQPYPQQPQ þ/þb

g5 (66!78) FPQQPQQPYPQQP !/þb
g5 (102!113) FSQPQQQFPQPQ !/þb
g36 (140!150) QQPQQSFPQQQ !/þc
g36 (140!150, E 148) QQPQQSFPEQQ þ/þ
g5 (228!236, E 232) IIQPEQPAQ þ
a2 (57!68) QLQPFPQPQLPY !
a2 (57!68, E 65) QLQPFPQPELPY þ
a2 (62!75) PQPQLPYPQPQLPY !
a2 (62!75, E 65) PQPELPYPQPQLPY þ
a2 (62!75, A 63, E 65) PAPELPYPQPQLPY !
a2 (62!75, E 65, A 71) PQPELPYPQAQLPY !
a2 (62!75, E 65, A 72) PQPELPYPQPALPY þ
a2 (226!237) PSGQGSFQPSQQ þ
a2 (226!235) PSGQGSFQPS !
a2 (227!238) SGQGSFQPSQQN þ
a2 (229!238) QGSFQPSQQN !
LMW 156 (40!59) QQQQPPFSQQQQSPFSQQQQ þ
LMW 17 (46!60) QQPPFSQQQQQPLPQ þ
HMW2 (722!734) GQQGYYPTSPQQS þ
HMW2 (722!731) GQQGYYPTSP !
HMW2 (724!735) QGYYPTSPQQSG þ
HMW2 (726!735) YYPTSPQQSG !

a
One-letter code for amino acids.
b
Native/tTG treated.
c
Native/acid-heat treated.

of single positions with an alanine residue indicated Future Prospects

that the sequence region 63!71 was essential for the
Research work will continue on full characterization
stimulatory effect. T cells of CD patients recognized
of all epitopes within proteins from wheat and related
also natural peptic fragment of the C-terminal domain
cereals that exacerbate CD. Recombinant proteins
of a-gliadins. The smallest active peptides included
produced by transgenic microorganisms will aid
the residues 226!237 and 227!238, respectively.
these investigations. Analytical systems for the detec-
Deamidation of glutamine residues was not neces-
tion of such epitopes in foods for CD patients will be
sary for the stimulatory effect. By combining high-
advanced in terms of their specificity and sensitivity.
performance liquid chromatography (HPLC) and
Scientific knowledge about the molecular mechanism
mass spectrometry peptides from digested gluten de-
of CD will increase step by step and facilitate the
rived from LMW and HMW subunits of glutenin
development of therapies, for example, based on
were also identified as activating T cells from CD
immuno-modulation or the application of specific en-
patients. The effect of deamidation by tTG has
zymes for detoxification of proteins. Wheat, rye, and
been shown to be heterogeneous and can be positive,
barley proteins might be modified by gene engineering
neutral, and negative. Altogether, numerous immuno-
to CD inactive epitopes without loss of their wished
dominant peptides from gluten have been identified
functionality as bread-making properties of wheat.
and much more epitopes are thought to exist. These
in vitro experiments with isolated T cells pose a lot
See also: Cereals: Overview; Protein Chemistry. Gluten
of questions, regarding the relations between the
and Modified Gluten. Nutrition: Effects of Food Process-
amino acid sequences and the stimulatory effects, ing. Taxonomic Classification of Grain Species.
the extent to which the stimulatory peptides reach Appendix: Foods for Celiac Diets.
the small intestinal mucosa after exposure to gastric
and duodenal proteases and if these peptides are re-
sponsible for toxicity leading to enteropathy. Up to Further Reading
now in vivo toxicity of peptides able to stimulate Auricchio S, Greco L, Maiuri L, and Troncone R (eds.)
T cells has been proven in only one case (peptide (1999) Proceedings of the Eighth International Sympo-
a 56!75, Table 2). sium on Coeliac Disease. Naples, Italy: JGC Editions.

Ciclitira PJ (2001) AGA technical review on celiac sprue.
Gastroenterology 120: 1526!1540.
Cornell HJ and Wills-Johnson G (2001) Structure activity
relationship in celiac-toxic gliadin peptides. Amino
Acids 21: 243!253.
Feighery C (1999) Coeliac disease. British Medical Journal
319: 236!239.
Howdle PD (ed.) (1995) Coeliac Disease. London:
Balliére’s Clinical Gastroenterology.
Mäki M and Tossavainen M (eds.) (2001) Proceedings of
the Workshop on Transglutaminases, Protein Cross-
linking and Coeliac Disease. Tampere, Finland: Coeliac
Disease Working Group.
CEREALS
Contents
Overview
Breakfast Cereals
Chemistry of Nonstarch Polysaccharides
Grain Defects
Grain Diseases
Grain ! Quality Attributes
Protein Chemistry
Evolution of Species
Overview
C Wrigley, Food Science Australia and Wheat CRC,
North Ryde, NSW, Australia
ª 2004, Elsevier Ltd. All Rights Reserved.
Introduction
The cereal grains are defined as ‘‘flowering plants of
the Grass Family (Poaceae or Gramineae), whose
seeds are used as food.’’ The name ‘‘cereal’’ derives
from Ceres, the Roman goddess of grain. Colloqui-
ally, the word ‘‘cereal’’ has also come to refer to
the range of breakfast foods, e.g., corn flakes, made
from the cereal grains. The words ‘‘seed,’’ ‘‘kernel,’’ or
‘‘caryopsis’’ are also used to denote the cereal grain.
In addition, the term ‘‘corn’’ is sometimes used for
CEREALS/Overview 187
Marsh MN (ed.) (1992) Coeliac Disease. Oxford: Black-
well Scientific Publications.
Marsh MN (ed.) (2000) Methods in Molecular Biology.
Totowa, NJ: Humana Press.
Schuppan D (2000) Current concepts of celiac disease
pathogenesis. Gastroenterology 119: 234!242.
Sollid LM (2000) Molecular basis of celiac disease. Annual
Review of Immunology 18: 53!81.
Troncone R and Auricchio S (1991) Gluten-sensitive
enteropathy (celiac disease). Food Reviews Interna-
tional 7: 205!231.
Wieser H (1996) Relation between gliadin structure and
celiac toxicity. Acta Paediatrica Supplement 412: 3!9.
the grains of the cereal species in general, but more
often ‘‘corn’’ denotes the cereal species maize, also
known as ‘‘Indian corn.’’ A wheat seed is shown
in Figure 1, as it appears by scanning electron
microscopy.
The cereal grain serves two contrasting functions.
1. For the plant, the mature grain is solely of signif-
icance as a seed, namely, the means by which the
species is perpetuated. When the plant has died,
the ongoing life of the cereal seed is in its embryo or
germ (Figure 2) (see Grain, Morphology of Inter-
nal Structure and Grain and Plants, Morphology).
Most of the grain’s mass is taken up by the endo-
sperm, which is the storage organ of the grain. It
contains the starch and protein for the ‘‘rainy day’’
when moisture will trigger the dormant seed to
start swelling and producing roots and a shoot.
In that situation, the endosperm provides the