Post on 30-Mar-2015
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Sorting Through Gluten Free
Sandy Arner, RD, LDNClinical Dietitian
James H. Quillen VA Medical CenterMarch 26, 2013
Disclosure Slides
Financial InterestI, Sandra Arner, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation
DrugsI, Sandra Arner, DO NOT anticipate discussing any unapproved/ investigative use of a commercial product/device during this activity or presentation
Describe three symptoms of celiac disease State two conditions associated with
untreated celiac disease Identify three grain alternatives that are
gluten free
Learning Objectives
Autoimmune digestive disease
Damages villi of small intestine Interferes with absorption of nutrients from food
Those with CD cannot tolerate gluten Also called
Gluten-sensitive enteropathy Sprue Non-tropical sprue Celiac sprue
It is NOT an allergy
What Is Celiac Disease (CD)
Still unknown
Cause of Celiac Disease
General name for prolamins (storage proteins)
in wheat, rye, barley Toxic prolamins
Gliadin in wheat Secalin in rye Hordein in barley
What is Gluten?
1 in 133 or 1% of American population has
Celiac Disease or CD (about 3 million people)¹ 1 in 141 or 0.71% of Americans have CD² In 70% of identical twin pairs, both twins have
the disease³ Family members who have an autoimmune
disease are at a 25% increased risk of having celiac disease³
Some CD Statistics
³Nationl Foundation For Celiac Awareness, Updated Feb. 28, 2013
¹Prevalence of Celiac Disease in At-risk and Not-at-risk Groups in the United States. Arch Int. Med. (2003) 163:286
²The American Journal of Gastroenterology 107, 1538-1544 (October 2012)
Estimated 85% of Americans who have celiac disease are
undiagnosed or misdiagnosed with other conditions¹ 6-10 years is the average time a person waits to be correctly
diagnosed² 5-22% of celiac patients have an immediate family member
(1st degree relative) who also has celiac disease¹ Burden of disease over four-year period per patient:
Celiac-free males: $4,019 Males with CD: $14,191¹
May is Celiac Awareness Month
Statistics (cont’d)
¹National Foundation for Celiac Awareness, Updated Feb. 28, 2013²Source: Daniel Leffler, MD, MS, The Celiac Center at Beth Israel Deaconness Medical Center
Symptoms Celiac Disease
Abdominal pain Bloating/gas Diarrhea and/or
constipation Indigestion/reflux
(“heartburn”) Nausea and vomiting Fatigue/lethargy Muscle weakness Itchy skin rash Tingling/numbness Mouth sores
Lactose intolerance Bone pain Easy skin bruising Edema of hands and
feet Joint pain Delayed growth Weight loss or gain Osteoporosis Headaches Depression/irritability Hair loss
Symptoms of CD (cont’d)
Iron, folate and/or vitamin B12 deficiency
Other vitamin and mineral deficiencies (A,D, E, K, calcium)
Elevated liver enzymes
Discolored teeth
Migraine headaches Depression Menstrual
irregularities Infertility in both
women and men Recurrent
miscarriages
An immediate family member with CD Presence of HLA-DQ2 and HLA-DQ8 genes
About 95% of people with celiac disease have the HLA-DQ2 gene
Most of the remaining 5% have the HLA-DQ8 gene Major life event, emotional stress, pregnancy, or
surgery in those who are genetically predisposed Those with other autoimmune disease Those with another genetic disorder Infants—exposure to gluten before 3 months of
age
Celiac Disease Risk Factors
Some Disorders/Conditions Associated More Frequently with
CD Type I diabetes Thyroid disease Liver disease Sjögren’s syndrome Lupus Addison’s disease
Scleroderma Alopecia areata Rheumatoid arthritis Turner syndrome Raynaud’s syndrome
Symptoms Blood test Small bowel biopsy
Should be tested while on a gluten-containing diet
Diagnosis of CD
No standardization in testing for diagnosis of
CD Anti-tissue transglutaminase antibodies (tTGA) Anti-endomysium antibodies (EMA)
Gluten free diet should not be started before blood tests and biopsy
Serologic Tests
Diagnosis:
Intestinal Biopsy A biopsy of the small
intestine can confirm the findings of the blood test. Celiac disease damages or destroys the villi in the intestine
Diagnosis—The Biopsy
What Does Celiac Disease Look Like?
Very small percentage of people with celiac
disease do not respond to a gluten-free diet. May be prescribed glucocorticoids or at times
immunosuppressants are indicated to induce remission
Refractory Celiac Disease
Another form of celiac disease Chronic skin condition
Intense burning Itchy and blistering rash Often misdiagnosed as eczema, contact
dermatitis, allergies, hives, herpes, or psoriasis Many with DH have varying degrees of small
intestinal villous atrophy Diagnosis—skin biopsy from unaffected skin
adjacent to blisters or erosions Treatment is a strict gluten free diet for life
Dermatitis Herpetiformis (DH)
MalabsorptionMalnutrition Low blood glucose or swings in blood glucose Osteoporosis Infertility Neurological problems Lactose intolerance Cancer
Some Complications of Untreated CD
Only known treatment is strict gluten free
diet for life! Additional vitamin and mineral supplements may
be needed to correct malnutrition Some may also need to eliminate lactose until
damaged bowel is healed
Treatment for CD
Contain Gluten (from
wheat)
Atta Bulgur Couscous Durum Einkorn Emmer Farina Graham flour Hydrolyzed wheat protein Kamut Motzoh, Matzoh meal Modified wheat starch
Seitan Semolina Spelt (a form of wheat)
Dinkel Farro or Faro
Triticale Wheat Wheat bran Wheat flour Wheat germ Wheat starch
Contain Gluten (from
barley)
Ale Barley (flakes, flour,
pearl) Beer Brewer’s yeast Lager
Malt Malt extract, malt
syrup, malt flavoring Malt vinegar Malted milk
Rye bread Rye flour
Contain Gluten (from rye)
Commonly Have GlutenRed Flags For
Gluten
In bread, cereal, pasta, crackers, baked goods Wheat Rye Barley
“Hidden” Gluten Processed meat Potato chips French fries Breaded foods Malt (made from barley) Hydrolyzed Vegetable Protein (often
contains wheat) Sauces Soy sauce (made from soy & wheat) Marinades Gravy Salad dressings Candy Flavored coffees and teas Nutritional supplements Soups
Controversial Oats
Safety of oats much debated Barley often contaminates
oats Wheat contaminates oats Only consume pure,
uncontaminated oats Best to be labeled or
certified as “gluten free”
Oatmeal Oat bran Oat flour Oats
Gluten Free Grains/Flours/Starches
Rice Corn (maize) Soy flour Potato flour Tapioca Bean flour Garfava flour Sorguhm Quinoa Potato
flour/starch
Millet Buckwheat Arrowroot flour Amaranth Teff Montina® (Indian ice
grass) Flax Nut flours Cornmeal Cornstarch
Buy items made with whole grain flour and bean
flour to get healthier nutrients GF often lower in fiber
Purchase products with added vitamins and minerals
Refined carbohydrates often in GF products generally make baked goods higher in calories and total carbohydrate than regular versions
Replacing regular bread, muffins, baked goods for GF products without regards to calories weight gain
Using Gluten Free Flours
MAY Contain Gluten
•Brown rice syrup •Breading & coating
mixes •Croutons •Energy Bars •Flour or cereal
products •Imitation bacon •Imitation seafood
•Marinades •Panko (Japanese
bread crumbs) •Pastas •Processed luncheon
meats •Sauces, gravies •Self-basting poultry •Soy sauce or soy
sauce solids
MAY Contain Gluten
•Soup bases •Stuffings, dressing •Thickeners (Roux) •Communion wafers •Herbal supplements •Prescription drugs
& over-the-counter medications
Lipstick
•Nutritional supplements
•Vitamins & mineral supplements
•Play dough: a potential problem if hands are put on or in the mouth while playing with play dough Hands should be
washed immediately after use
Alcohol
Beer and Ale
Has gluten from barley malt
ONLY have gluten free beers or ale that are so labeled And IF your
healthcare provider allows
Wine, Distilled Alcohol
Wine and distilled alcohol are generally safe As long as your
healthcare provider allows alcohol
Incorporate whole foods into
gluten free diet Reverse nutritional deficiencies Restore gut health
Let Food Be Thy Medicine
Adhere to a total (100%) gluten free diet Need nutrient-dense foods to regain health Need proper nutrition to restore gut health Focus on whole foods vs. highly processed gluten free
packaged foods (& prepare without ingredients that contain gluten)
Meat Fish Eggs Rice Beans Fruits Vegetables
Nutrient-Dense Gluten Free Diet
Preparing foods on common surfaces with gluten
items Using utensils that are not thoroughly cleaned after
preparing gluten-containing foods Using a common toaster for GF bread and regular
bread is a major source of contamination Sharing flour sifters with gluten-containing flours Deep frying foods cooked in oil shared with breaded
products containing gluten Using knives for spreadable condiments for both
gluten free and gluten-containing products
Cross-Contamination Concerns
A must for those with celiac
disease Carefully check the ingredient list
Label Reading
Food labels to clearly identify wheat and other common food allergens in list of ingredients
Eight major foods or food groups— Milk Eggs Fish (e.g., bass, cod, flounder) Crustacean shellfish (e.g., crab, lobster, shrimp) Tree nuts (e.g., almonds, walnuts, pecans) Peanuts Wheat Soybeans
Develop and finalize rules for term “gluten free” on product labels (not done yet)
Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA)
(Public Law 108-282, Title II) of the FDA
FDA gluten free labeling to be voluntary FDA proposing to define the food labeling term "gluten-
free" to mean a food bearing this claim does not contain any of the following: An ingredient that is a "prohibited grain," which refers to any
species of wheat (e.g., durum wheat, spelt wheat, or kamut), rye, barley, or their crossbred hybrids
An ingredient (e.g., wheat flour) that is derived from a "prohibited grain" and that has not been processed to remove gluten
An ingredient (e.g., wheat starch) that is derived from a "prohibited grain" that has been processed to remove gluten, if the use of that ingredient results in the presence of 20 micrograms or more gluten per gram of food (i.e., 20 ppm)
Or 20 micrograms or more gluten per gram of food
“Gluten Free”
Some Gluten Free Symbols
Eating Gluten Free
Grocery Shopping
MANY gluten free foods available now
Various stores carry gluten free foods
Eating Out
Must ask, ask, ask Some restaurants do
have gluten free menu items
Iron Folate Niacin Vitamin B12 Calcium Phosphorus Zinc Fiber
GF Diet Potentially Low in Nutrients
Source: Academy of Nutrition and Dietetics Celiac Disease Toolkit 2011
Assess Biochemical Data & Results of Medical
Procedures Gastrointestinal profile Intestinal biopsy Or skin biopsy for DH Celiac antibodies
IgA-tTG IgA-EMA IgA/IgG-DGP Total IgA
Nutritional anemia profile Hemoglobin Hematocrit Folate Ferritin Vitamin B12
Vitamin profile Thiamin Vitamin B6 25-hydroxy vitamin D
Mineral profile Copper Zinc
Lipid profile Electrolyte profile Renal profile Bone density screening
Source: Academy of Nutrition and Dietetics Celiac Disease Toolkit 2011
Nutrition Intervention
Education on gluten free diet
Consumption of whole/enriched gluten- free grains & other products
Consideration of MV and mineral supplement
Inclusion of gluten free oats as tolerated
Calcium/vitamin D for reduced bone density
Iron supplementation for iron deficiency anemia
Education on food cross-contamination
Source: Academy of Nutrition and Dietetics Celiac Disease Toolkit 2011
Reverse Nutritional Deficiencies
Iron Calcium Vitamin D Zinc Magnesium
Vitamin K Folate Vitamin B6 Vitamin B12 Fiber
Foods first
Supplements as necessary Nutrients often cannot be absorbed until
intestinal site of absorption heals Improvement in nutrient stores important
Indicates intestines are healing Indicates adherence to gluten free diet
Follow up blood to test antibodies and nutrient levels is important
Reverse Nutrition Deficiencies (cont’d)
Ensure medications and supplements are
gluten free Be aware of physiological reasons someone
may not be absorbing certain nutrients Then make recommendations and monitor
Provide tips for maximizing nutrient uptake
Reverse Nutrition Deficiencies (cont’d)
Number one way to improve gut health is
removing gluten from diet May take longer to restore gut health for some
Some may need steps beyond gluten free diet Digestive health and integrity of gut lining
play important roles in immune health
Restore Gut Health
Wheat free is not gluten free When in doubt, go without May be contamination in food
preparation Stay symptom free with gluten free Eating gluten free is work
Remember
Those who suffer from celiac disease Those who are sensitive to gluten Those who think gluten free products are
healthier Those who follow a trend in the news
Who Is Buying Gluten Free
Gluten-degrading enzymes Modified grains that lack immunogenic
compounds Zonulin inhibitors that decrease intestinal
permeability Anti-inflammatory therapy Immunotherapy Hookworms
Future Possibilities
The cost of gluten-free (GF) food that is in EXCESS
of the cost of the gluten containing food that you are replacing
The full cost of special items needed for a GF diet may be deducted
If you make a special trip to a store to purchase GF foods, the actual cost of your transportation to and from the store is deductible
The full cost of postage or other delivery expenses for GF foods made by mail order are deductible
Tax Deductions
Celiac Disease Foundation:
http://www.celiac.org Celiac Sprue Association:
http://www.csaceliacs.info National Foundation for Celiac Awareness:
http://www.celiaccentral.org NIH Celiac Disease Awareness Campaign:
http://celiac.nih.gov National Digestive Diseases Information Clearinghouse http://digestive.niddk.nih.gov Celiac.com http://www.celiac.com
Helpful Web Sites