12/18/2018

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The Need for Gluten-Free“One Man’s Food is Another Man’s Poison”

Sponsor Disclosure: Support for this presentation was provided by the Foodservice Express division of Med-Diet, Inc. The material herein is for educational purposes only.

Reproduction or distribution of these materials is prohibited except as expressly provided by Med-Diet, Inc.

Copyright 2017 Med-Diet, Inc. All rights reserved.

Learning Objectives

After completing, the learner will:

• Distinguish between celiac disease, non-celiac gluten sensitivity and wheat allergy

• Identify the dietary needs for celiac disease, non-celiac gluten/wheat sensitivity and wheat allergy

• Recognize the variety of resources that support gluten-free living

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Prevalence

• ~15 million with diagnosed food allergies• 5% of children

• 4% of adults

• Food Intolerance / Sensitivity• Not quantifiable

• 1:3 people claim issues• P.S. That’s 100 million people

• <1% of popu. w/diagnosed celiac disease

I can’t eat that I’m ‘allergic’ to it ...

…I follow a gluten-free diet.

Defining an Allergy

• Abnormal response to a ‘normal’ food

• Triggered by immune system• Body produces antibody IgE

• Reaction may be immediate or hours after exposure

• Response ranges from mild to severe

• Risk is tied to genetics

• Proteins in the offending food have survived usual breakdown from cooking, stomach acids and/or digestive enzymes

The Allergic Response

• Response & timing unique to individual

• Protein fragments are introduced and allergic reactions follow:• Itching in mouth; throat discomfort

• Abdominal discomfort with digestion• Vomiting, diarrhea, GI pain

• Allergens in bloodstream• Drop in blood pressure

• Upon reaching the skin → hives, eczema

• Reaching the lungs → wheezing

8 Foods cause 90%* of Allergies

• Milk

• Eggs

• Wheat

• Soybeans

• Peanuts

• Tree Nuts

• Shellfish

• Fish

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*The other 10% is any number of other foods.

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Definition – Intolerance / Sensitivity

• Intolerance / Hypersensitivity - not a true allergy• Non-IgE mediated

• Not linked to genetics

• Abnormal physiological or psychological response to food or food compound

• Varied mechanisms of action:• Metabolic: absence of chemicals/enzymes to digest a food (e.g. lactose)

• GI: Inability to absorb nutrients (e.g. fructose)

• Pharmacologic: natural/artificial food chemical sensitivity (e.g. salicylates, nitrates, caffeine)

• Psychological: extreme dislike for a food

Intolerance/Sensitivity Response• Chronic vs. acute; less obvious

• Dose / exposure dependent

• Symptoms vary greatly• Skin: rash, hives, dermatitis, eczema

• Respiratory: nasal congestion, sinusitis, throat irritation, asthma, cough

• GI: mouth ulcers, cramping, nausea, gas, diarrhea, IBS

• Anaphylaxis (rare)

Tip to Remember

• Allergies involve the immune system• Can be acute and life-threatening

• However, no long-term consequences

• Intolerances / Sensitivities involve the GI tract• Rarely life-threatening

• Long-term consequences possible; not likely

Gluten Intolerance?Gluten or Wheat Sensitivity?Wheat Allergy?

Sorting Out The Situation

Just What is Gluten?

• A Protein

• Found in cereal grains

• Gluten is composed of two protein factions: • Gliadin (a prolamin)

• Wheat = gliadin

• Barley = hordein

• Rye = secalin• Triticale = Wheat + Rye

• Glutenin (a glutelin)

Linking Gluten to Celiac Disease

• Celiac is a genetic disorder• 1:100

• Eating gluten triggers an autoimmune reaction• Body triggers an attack on the intestinal villi

• Leads to malabsorption

• Left untreated = malnutrition

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Intestinal Villi Dermatitis Herpetiformis

Celiac sounds like an Allergy

• Allergies (especially wheat) can be outgrown

• An allergy doesn’t create malabsorption celiac does

Celiac: Symptoms & Diagnosis

• 200+ symptoms• Diarrhea, malnutrition, weight loss

• Isolated nutrient deficiencies but no GI issues (e.g. bone disease)

• Suspicion Blood test

• Genetic testing – fairly new

• Biopsy; with positive blood test

• Only Treatment = gluten-free diet

Associations

• Allergies

• Asthma

• Arthritis

• ADD

• Autism

• Cancer (GI)

• T1 Diabetes

• Epilepsy

• Fibromyalgia

• Kidney disease

• Migraines

• Nerve disease

• Osteoporosis

• Thyroid disorders

Common Sources of Gluten

• Barley malt/extract

• Bran

• Bulgar

• Couscous

• Durum

• Einkorn

• Emmer

• Farina

• Faro

• Graham Flour

• Hydrolyzed Veg Protein

• Kamut• Matzo Flour/Meal• Orzo• Panko• Seitan• Semolina• Spelt/Spelta• Triticale• Udon• Wheat Germ • Wheat Starch

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Hidden Sources of Gluten

• Processed foods• Soups, bouillon, mixes

• Communion wafers

• Lipstick, toothpaste, chewing gum, mints

• Licorice and some candies

• Soy sauce, marinades

• Modified food starch

• Supplements

• Medications

How much gluten is tolerated?

• NONE

• Small amounts of gluten can damage the intestine• Small = 1/7000th of a slice of wheat bread equates to the ‘less than 20 ppm

gluten’

Non-Celiac Gluten Sensitivity**

• Greater occurrence than celiac• Often self-diagnosed

• Diagnosed NCGS/NCWS IF removing gluten from diet helps

• Negative test for celiac

• No intestinal villi destruction (?)

• BUT symptoms linked to gluten• c/o diarrhea, bloating, fatigue, “foggy brain”

** Also called Non-Celiac Wheat Sensitivity

Non-Celiac Gluten Sensitivity**

• ?? No intestinal villi destruction • New research questions this

• Cell damage is observed

• Unclear that it is the gluten

** Also called Non-Celiac Wheat Sensitivity

If not gluten, then what?

• Almost 1/3 of adults in US have digestive sensitivities• Symptoms are similar to celiac disease

• Certain CHOs can be difficult to digest• F – fermentable

• O - oligosaccharides

• D - disaccharides

• M- monosaccharides

• And

• P - polyols

High / Low FODMAP Grains

HIGH

• Barley

• Bran

• Cous cous

• Rye

• Semolina

• Spelt

• Wheat

LOW

• Buckwheat

• Corn

• Oats

• Quinoa

• Rice

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Wheat Allergy

• Allergy to the whole protein component in wheat.

• Evidenced by allergic reaction• Swelling, itching or irritation– especially around mouth

• Nasal congestion

• Itchy watery eyes

• Difficulty breathing

• Anaphylactic shock [swelling of throat, rapid heartbeat, dizziness/fainting]

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Wheat Allergy

• “True” wheat allergy considered rare

• Affects 0.4% of children and 0.5% of adults• ~65% of children typically outgrow

• ~75% of all grain products in the US contain wheat flour

• Hidden sources: processed foods, cosmetics, bath products, play dough, medications, lotions

Wheat Allergy

• No:• Wheat

• Triticale (Wheat + Rye)

• Generally tolerated grains:• Aramanth

• Barley

• Buckwheat

• Corn

• Millet

• Oats

• Quinoa

• Rice / Wild Rice

• Rye

• Sorghum

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Celiac Disease (CD) Gluten Sensitivity (GS) Wheat Allergy(WA)

Time between gluten exposure & symptoms

Weeks – Years Hours – Days Minutes - Hours

Pathogenesis Autoimmunity Immunity? (Innate) Allergic ImmuneResponse

HLA (the genetic testing) HLA DQ2/8 restricted(~97% positive)

Not HLA DQ2/8 restricted(50% positive)

Not HLA DQ2/8 restricted35-40% positive)

Autoantibodies Almost always present Always absent Always absent

Enteropathy (inflammation of GI tract)

Almost always present Always absent Always absent

Symptoms Both intestinal and extra intestinal(indistinguishable from GS & WA with GI symptoms)

Both intestinal and extra intestinal(indistinguishablefrom CD & WA with GI symptoms)

Both intestinal and extra intestinal(indistinguishable from CD & GS when presenting with GI symptoms)

Adapted from the book Gluten Freedom by Alessio Fasano, MD 30

Adapted from the book Gluten Freedom by Alessio Fasano, MD

Gluten-Related Disorders

Pathogenesis

Autoimmune

Celiac Disease

Symptomatic Silent Potential

Gluten

Ataxia

Dermatitis Herpetiformis

Allergic

Wheat

Allergy

Respiratory

Allergy

Food

Allergy

Wheat Dependent

Exercise Induced Anaphylaxis

Contact

Urticaria

Not Autoimmune Not Allergic

(Innate Immunity)

Gluten

Sensitivity

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Ingredients in packaged products may change without warning.

Check ingredient statements every time you shop/purchase.

If in doubt call the manufacturer.

Labeling Law

• MUST call out wheat• Any source of wheat must be identified

• Wheat free is not guaranteed Gluten Free• No requirement to call out barley or rye

Labeling Law

• Gluten is not a required disclosure

• Labelling gluten-free is optional

• IF labeled gluten-free rules must be met• GF means the food does NOT contain:

• An ingredient that is a gluten-containing grain

• An ingredient derived from a gluten-containing grain • Unless it has been processed to remove the gluten

• <20 ppm of gluten is threshold• Example: 1 kg (1 million milligrams) must have less than 20 mg of gluten

Reminders

• Avoid Cross–Contact• Separate storage, prep areas, utensils…

• Train staff• Consider vulnerable patients/residents

• Report incidences

Resources / References

• Celiac Disease Foundation• www.celiac.org

• The Gluten Intolerance Group• www.gluten.net

• National Foundation for Celiac Awareness• www.celiaccentral.org

• Celiac Sprue Association• www.csaceliacs.org

• Gluten Free Drugs• www.glutenfreedrugs.com

• Gluten Free Watch Dog• www.glutenfreewatchdog.org

• Apps• Find Me Gluten Free

• Identifies eateries with GF options

• Triumph Dining Cards• Print & App• Various cuisine & languages• Explains GF diet

o Gluten Freedom. Alessio Fasano, MD. 2014 Wiley New York, New York.o Celiac Disease Nutrition Guide. Third Edition Tricia Thompson, MS, RD. 2014 AND

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Looking to the Future

• Available Now (enzymes):• Gluten Manager (Intregrative Therapiutics)

• GlutenAid (CVS)

• Rx currently in Trials:• Repair leaky gut; enzymes to digest the gluten proteins; antibodies and other

novel ideas

Summary of Clinical Trial Phases

PHASE PRIMARY GOAL DOSE PATIENT MONITORTYPICAL NUMBER OF PARTICIPANTS

NUMBER OF PARTICIPANTS NOTES

Preclinical

Testing of drug in non-human subjects, to gather efficacy, toxicity and pharmacokinetic information

unrestrictedA graduate level researcher (Ph.D.)

not applicable (in vitro and in vivo only)

Phase 0

Pharmacokinetics particularly oral bioavailability and half-life of the drug

very small, subtherapeutic

clinical researcher 10 people often skipped for phase I

Phase ITesting of drug on healthy volunteers for dose-ranging

often subtherapeutic, but with ascending doses

clinical researcher 20-100determines whether drug is safe to check for efficacy

Phase IITesting of drug on patients to assess efficacy and safety

therapeutic dose clinical researcher 100-300

determines whether drug can have any efficacy; at this point, the drug is not presumed to have any therapeutic effect whatsoever

Phase III

Testing of drug on patients to assess efficacy, effectiveness and safety

therapeutic doseclinical researcher and personal physician

1000-2000

determines a drug’s therapeutic effect; at this point, the drug is presumed to have some effect

Phase IVPostmarketing surveillance – watching drug use in public

therapeutic dose personal physiciananyone seeking treatment from their physician

watch drug’s long-term effect

Thank you for participating in today’s session!

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This presentation is intended to provide general information about the gluten free diet but is not intended to provide medical advice.

Presentation Author: Debra Zwiefelhofer, RDN, LD

Your Special Diet Partner Post - Test

Is this gluten free?

Fiesta Lime Chicken® Grilled chicken done fiesta-style with zesty lime sauce, Mexi-ranch and Jack-cheddar. Served with crisp tortilla strips, seasoned rice and freshly-made pico de gallo.

What questions would you have before you ordered?

Whereis the Wheat?

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BREAKFAST

ORANGE JUICECEREAL OF CHOICE

BAKED EGG OMELETTOAST

MARGARINEJELLY

COFFEE/SUGAR/CREAMER /MILK

LUNCHITALIAN CRUSTED FISH

SOUR CREAM MASHED POTATOESSEASONED PEAS

BREAD / MARGARINERASPBERRY PARFAIT SQUARE

COFFEE/SUGAR/CREAMER/MILKGARNISH LEMON WEDGE

SLICED TURKEYKEY LARGO VEGETABLES

Hint: You should find 7-8 suspect menu items