Celiac Disease presented to the Oregon Association of ...

04/10/23 Sara Kristine Becker, MD Northwest Primary Care Group, PC

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Celiac Disease and Autoimmune Issues

Celiac Disease and Autoimmune Issues

Oregon Association of Electrologists Oregon Association of Electrologists ConferenceConference

April 29,2006April 29,2006


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What is Celiac DiseaseWhat is Celiac Disease

• Celiac disease is a disorder that causes Celiac disease is a disorder that causes problems in your intestines when you eat problems in your intestines when you eat gluten, which is in wheat, rye, barley and gluten, which is in wheat, rye, barley and oats. Gluten is like a poison to people with oats. Gluten is like a poison to people with celiac disease. celiac disease.


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• Celiac disease used to be called Sprue.Celiac disease used to be called Sprue.• There is also illness called Tropical Sprue There is also illness called Tropical Sprue

which is not related.which is not related.


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• Gluten damages the intestines. This damage Gluten damages the intestines. This damage keeps your body from taking in many of the keeps your body from taking in many of the nutrients in the food you eat. These include nutrients in the food you eat. These include vitamins, calcium, protein, carbohydrates, vitamins, calcium, protein, carbohydrates, fats and other important nutrients. Your fats and other important nutrients. Your body can't work well without these body can't work well without these nutrients. nutrients.


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Diseases Associated with Celiac DiseaseDiseases Associated with Celiac Disease


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How Celiac Disease Causes SymptomsHow Celiac Disease Causes Symptoms

• The damage to the small bowel causesThe damage to the small bowel causes• Malabsorbtion of nutrients causing failure Malabsorbtion of nutrients causing failure

to thriveto thrive• Complex anemia from inability to absorb Complex anemia from inability to absorb

iron, folic acid, and B12iron, folic acid, and B12• Severe damage can prevent absorbtion of Severe damage can prevent absorbtion of

fat soluble vitamins A, D, E , and Kfat soluble vitamins A, D, E , and K• Decreased absorbtion of zincDecreased absorbtion of zinc


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How Common is Celiac DiseaseHow Common is Celiac Disease

• Celiac disease runs in the family. You inherited Celiac disease runs in the family. You inherited the tendency to get this disease from your parents. the tendency to get this disease from your parents. If 1 member of your family has celiac disease, If 1 member of your family has celiac disease, about 1 out of 10 other members of your family is about 1 out of 10 other members of your family is likely to have it. You may have this tendency for a likely to have it. You may have this tendency for a while without getting sick. Then something like while without getting sick. Then something like severe stress, physical injury, infection, childbirth severe stress, physical injury, infection, childbirth or surgery can "turn on" your celiac disease. or surgery can "turn on" your celiac disease.


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• The general incidence is 2.5 to 7.5 per The general incidence is 2.5 to 7.5 per thousand peoplethousand people

• More common in women then menMore common in women then men• May be the most predetermined condtion in May be the most predetermined condtion in

Humans (Hill, 2003, NIH, 2004)Humans (Hill, 2003, NIH, 2004)


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• According to The University of Maryland According to The University of Maryland School of Medicine Center for Celiac School of Medicine Center for Celiac Research, one in 133 people is considered Research, one in 133 people is considered to be gluten intolerant and more than 1.5 to be gluten intolerant and more than 1.5 million Americans are estimated to suffer million Americans are estimated to suffer from celiac disease. from celiac disease.


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GeneticsGenetics

• No one is sure why celiac disease happens, but it appears No one is sure why celiac disease happens, but it appears to run in families. You have a 5-10% chance of getting to run in families. You have a 5-10% chance of getting celiac disease if someone in your family has it. It's celiac disease if someone in your family has it. It's common in people from the northern European countries common in people from the northern European countries and the United States. How common? We think that about and the United States. How common? We think that about one in every 133 people has celiac disease in the United one in every 133 people has celiac disease in the United States. Over 50% who have celiac disease do not know it. States. Over 50% who have celiac disease do not know it. If all these people were diagnosed, celiac disease would be If all these people were diagnosed, celiac disease would be more common than Type 1 diabetes. Fortunately, more common than Type 1 diabetes. Fortunately, awareness is growing about the problem, and there are awareness is growing about the problem, and there are better ways of testing people for it. better ways of testing people for it.


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GeneticsGenetics

• Celiac disease -- also known as celiac sprue and Celiac disease -- also known as celiac sprue and GLUTEN-sensitive enteropathy -- is a prevalent (~1:100) GLUTEN-sensitive enteropathy -- is a prevalent (~1:100) food hypersensitivity disorder caused by an inflammatory food hypersensitivity disorder caused by an inflammatory response to wheat gluten and similar proteins of barley and response to wheat gluten and similar proteins of barley and rye.[1] The resulting intestinal inflammation often causes rye.[1] The resulting intestinal inflammation often causes symptoms related to malabsorption, but in many patients symptoms related to malabsorption, but in many patients extra-intestinal symptoms dominate, and in others the extra-intestinal symptoms dominate, and in others the disease is clinically silent. Genes encoding HLA-DQ2 and disease is clinically silent. Genes encoding HLA-DQ2 and HLA-DQ8 molecules are the single most important HLA-DQ8 molecules are the single most important predisposing genetic factor; however, although these predisposing genetic factor; however, although these polymorphisms are necessary, they are not sufficient for polymorphisms are necessary, they are not sufficient for disease development. disease development.


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GeneticsGenetics

• HLA-DQ2 and HLA-DQ8 predispose to disease development by HLA-DQ2 and HLA-DQ8 predispose to disease development by preferential presentation to mucosal CD4+ T cells of proline-rich preferential presentation to mucosal CD4+ T cells of proline-rich gluten peptides that have undergone deamidation by the enzyme tissue gluten peptides that have undergone deamidation by the enzyme tissue transglutaminase (Transglutaminase 2; TG2). Fewer details are known transglutaminase (Transglutaminase 2; TG2). Fewer details are known about the effector mechanisms that lead to the development of the about the effector mechanisms that lead to the development of the typical celiac lesion -- villous atrophy, crypt hyperplasia and typical celiac lesion -- villous atrophy, crypt hyperplasia and infiltration of inflammatory cells (Figure 1) -- but, once activated, infiltration of inflammatory cells (Figure 1) -- but, once activated, gluten-reactive CD4+ T cells produce cytokines and are likely to gluten-reactive CD4+ T cells produce cytokines and are likely to control the inflammatory reactions that produce the celiac lesion. This control the inflammatory reactions that produce the celiac lesion. This notion is based on the nature of the HLA association and the unique notion is based on the nature of the HLA association and the unique presentation of gluten antigens to T cells by HLA-DQ2 or HLA-DQ8 presentation of gluten antigens to T cells by HLA-DQ2 or HLA-DQ8 in the intestine. Recent advances have improved our understanding of in the intestine. Recent advances have improved our understanding of the molecular basis for this disorder,[2] and new targets for rational the molecular basis for this disorder,[2] and new targets for rational therapy have been identified. This paper reviews concepts for new therapy have been identified. This paper reviews concepts for new treatments and their current status.treatments and their current status.

•


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GeneticsGenetics

• The small-intestinal lesion in patients with celiac disease. Factors that The small-intestinal lesion in patients with celiac disease. Factors that contribute to the development of celiac disease and that can be targeted for contribute to the development of celiac disease and that can be targeted for new therapies are depicted. Proline-rich fragments of gluten that are resistant new therapies are depicted. Proline-rich fragments of gluten that are resistant to processing by luminal and brush-border enzymes survive digestion[5] and to processing by luminal and brush-border enzymes survive digestion[5] and can be transported across the mucosal epithelium as polypeptides. CD4+ T can be transported across the mucosal epithelium as polypeptides. CD4+ T cells in the lamina propria recognize predominantly deamidated gluten cells in the lamina propria recognize predominantly deamidated gluten peptides[37] in the context of HLA-DQ2 or HLA-DQ8 molecules on the cell peptides[37] in the context of HLA-DQ2 or HLA-DQ8 molecules on the cell surface of antigen-presenting cells (APCs).[38] The deamidation of gluten surface of antigen-presenting cells (APCs).[38] The deamidation of gluten peptides is mediated by tissue transglutaminase (TG2).[39-41] The gluten-peptides is mediated by tissue transglutaminase (TG2).[39-41] The gluten-reactive CD4+ T cells produce interferon (IFN)-γ on activation.[27] IFN-γ is reactive CD4+ T cells produce interferon (IFN)-γ on activation.[27] IFN-γ is also produced by T cells in the epithelium.[42] Interleukin (IL)-15, produced also produced by T cells in the epithelium.[42] Interleukin (IL)-15, produced by either mononuclear cells in the lamina propria or by enterocytes,[30,31] by either mononuclear cells in the lamina propria or by enterocytes,[30,31] stimulates T cells to migrate to the epithelium and facilitate killing of stimulates T cells to migrate to the epithelium and facilitate killing of enterocytes by upregulated expression of MIC by enterocytes and NKG2D by enterocytes by upregulated expression of MIC by enterocytes and NKG2D by intraepithelial T cells.[29,32] IL-15 production is stimulated by gluten.[28,29] intraepithelial T cells.[29,32] IL-15 production is stimulated by gluten.[28,29] Gluten can also induce production of the intestinal peptide zonulin, which acts Gluten can also induce production of the intestinal peptide zonulin, which acts on tight junctions and increases epithelial permeability.[43] Adapted with on tight junctions and increases epithelial permeability.[43] Adapted with permission from[2] ©(2002) Macmillan Publishers Ltd. permission from[2] ©(2002) Macmillan Publishers Ltd.


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GI Symptoms GI Symptoms

• Abdominal bloating and painAbdominal bloating and pain• DiarrheaDiarrhea• ConstipationConstipation• Nausea and VomitingNausea and Vomiting


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GI Symptoms GI Symptoms

• Classic Symptoms are rare.Classic Symptoms are rare.• Onset is variable which leads to delays in Onset is variable which leads to delays in

diagnosisdiagnosis• Most have symptoms for over a year before Most have symptoms for over a year before

diagnosisdiagnosis• Presentation may be a infant who does well but Presentation may be a infant who does well but

then develops irritability with pot belly, loose then develops irritability with pot belly, loose bulky stools, weight loss, or failure to thrive after bulky stools, weight loss, or failure to thrive after introduction of ceralintroduction of ceral

• May be less dramatic in older childrenMay be less dramatic in older children


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Clinical Presentation In YouthClinical Presentation In Youth

• Celiac disease can cause different problems at different times:Celiac disease can cause different problems at different times:• An infant with celiac disease may have abdominal pain and diarrhea An infant with celiac disease may have abdominal pain and diarrhea

(even bloody diarrhea), and may fail to grow and gain weight. (even bloody diarrhea), and may fail to grow and gain weight. • A young child may have abdominal pain with nausea and lack of A young child may have abdominal pain with nausea and lack of

appetite, anemia (not enough iron in the blood), mouth sores and appetite, anemia (not enough iron in the blood), mouth sores and allergic dermatitis (skin rash). allergic dermatitis (skin rash).

• A child could be irritable, fretful, emotionally withdrawn or A child could be irritable, fretful, emotionally withdrawn or excessively dependent. excessively dependent.

• In later stages, a child may become malnourished, with or without In later stages, a child may become malnourished, with or without vomiting and diarrhea. This would cause the child to have a large vomiting and diarrhea. This would cause the child to have a large tummy, thin thigh muscles and flat buttocks. tummy, thin thigh muscles and flat buttocks.

• Teenagers may hit puberty late and be short. Celiac disease might Teenagers may hit puberty late and be short. Celiac disease might cause some hair loss (a condition called alopecia areata). cause some hair loss (a condition called alopecia areata).


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Clinical Presentation In YouthClinical Presentation In Youth

• Some common symptoms of celiac disease are Some common symptoms of celiac disease are diarrheadiarrhea, decreased appetite, stomachache and , decreased appetite, stomachache and bloating, poor growth, and weight loss. Many kids bloating, poor growth, and weight loss. Many kids are diagnosed with the problem between 6 months are diagnosed with the problem between 6 months and 2 years of age. It makes sense because, at this and 2 years of age. It makes sense because, at this time, kids are getting their first taste of gluten in time, kids are getting their first taste of gluten in foods. For some people, the problems occur foods. For some people, the problems occur gradually and the symptoms may be terrible one gradually and the symptoms may be terrible one week and not as bad the next. Because of this, week and not as bad the next. Because of this, some people aren't diagnosed with the celiac some people aren't diagnosed with the celiac disease until they are older. disease until they are older.

http://www.kidshealth.org/kid/word/d/word_diarrhea.html


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Celiac Disease in AdultsCeliac Disease in Adults

• Adults who begin to be ill with celiac disease Adults who begin to be ill with celiac disease might have a general feeling of poor health, with might have a general feeling of poor health, with fatigue, irritability and depression, even if they fatigue, irritability and depression, even if they have few intestinal problems. One serious illness have few intestinal problems. One serious illness that often occurs is osteoporosis (loss of calcium that often occurs is osteoporosis (loss of calcium from the bones). A symptom of osteoporosis may from the bones). A symptom of osteoporosis may be night-time bone pain. About 5% of adults with be night-time bone pain. About 5% of adults with celiac disease have anemia. Lactose intolerance celiac disease have anemia. Lactose intolerance (problem with foods like milk) is common in (problem with foods like milk) is common in patients of all ages with celiac disease. It usually patients of all ages with celiac disease. It usually disappears when they follow a gluten-free diet. disappears when they follow a gluten-free diet.


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Diagnosis of Celiac DiseaseDiagnosis of Celiac Disease

• New blood tests can help your doctor diagnose New blood tests can help your doctor diagnose this disease. It's necessary to have these blood this disease. It's necessary to have these blood tests before you start a gluten free-diet. If you tests before you start a gluten free-diet. If you have dermatitis herpetiformis (an itchy, blistery have dermatitis herpetiformis (an itchy, blistery skin problem), you have celiac disease. The skin problem), you have celiac disease. The diagnosis can be confirmed with a biopsy (taking diagnosis can be confirmed with a biopsy (taking a piece of tissue using a thin tube that is put into a piece of tissue using a thin tube that is put into your intestines). The best confirmation, though, is your intestines). The best confirmation, though, is if your symptoms go away when you follow a if your symptoms go away when you follow a strict gluten-free diet. strict gluten-free diet.


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• If the screening tests show a person might If the screening tests show a person might have celiac disease, the next stop is usually have celiac disease, the next stop is usually a gastroenterologist, a doctor who specializes in a gastroenterologist, a doctor who specializes in digestive problems. This specialist may decide to digestive problems. This specialist may decide to take a sample of the person's small intestine to take a sample of the person's small intestine to look at under the microscope. This small sample is look at under the microscope. This small sample is called a called a biopsybiopsy. If a biopsy is done, the doctor will . If a biopsy is done, the doctor will give the person some special medicine to keep him give the person some special medicine to keep him or her comfortable during the procedure.or her comfortable during the procedure.

http://www.kidshealth.org/kid/word/b/word_biopsy.html


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• Someone who has a lot of stomachaches, Someone who has a lot of stomachaches, diarrhea, weight loss, or any of the other diarrhea, weight loss, or any of the other symptoms mentioned above should talk to symptoms mentioned above should talk to the doctor. It may or may not be celiac the doctor. It may or may not be celiac disease, but a doctor can help sort this out. disease, but a doctor can help sort this out. The doctor will usually order a screening The doctor will usually order a screening blood test. blood test.


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DiagnosisDiagnosis

• The North American Society of Pediatric The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition Gastroenterology, Hepatology, and Nutrition (NASPGHN) (2004) recommends that primary (NASPGHN) (2004) recommends that primary care providers consider celiac disease early in care providers consider celiac disease early in children with a combination of persistent diarrhea children with a combination of persistent diarrhea and poor weight gain, weight loss or failure to and poor weight gain, weight loss or failure to thrive. Children with recurrent gastrointestinal thrive. Children with recurrent gastrointestinal symptoms, including abdominal pain, anorexia, symptoms, including abdominal pain, anorexia, constipation, vomiting or other global symptoms constipation, vomiting or other global symptoms found in celiac disease found in celiac disease


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DiagnosisDiagnosis

• all children who are first degree relatives of all children who are first degree relatives of an individual with confirmed celiac disease, an individual with confirmed celiac disease, have type 1 diabetes, Down syndrome, have type 1 diabetes, Down syndrome, Turner syndrome, Williams syndrome, Turner syndrome, Williams syndrome, selective IgA deficiency or auto immune selective IgA deficiency or auto immune thyroiditis should be screened even if they thyroiditis should be screened even if they are without gastrointestinal symptoms are without gastrointestinal symptoms (NASPGHN, 2004). (NASPGHN, 2004).


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DiagnosisDiagnosis

• Although small bowel biopsy to determine Although small bowel biopsy to determine histological changes in the mucosa is the histological changes in the mucosa is the definitive diagnostic test for celiac disease, definitive diagnostic test for celiac disease, there are screening tests to help determine there are screening tests to help determine those children with high probability of the those children with high probability of the disease from those with low probability. disease from those with low probability.


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DiagnosisDiagnosis

• The currently recommended screening test is a The currently recommended screening test is a measurement of IgA antibody to human recombinant measurement of IgA antibody to human recombinant tissue trans glutaminase (tTG IgA) (NASPGHN, 2004). tissue trans glutaminase (tTG IgA) (NASPGHN, 2004).

• The tissue transglutaminase antibody test (tTG) has The tissue transglutaminase antibody test (tTG) has replaced the anti-gliadin (GAG IgA and AGA IgG) and the replaced the anti-gliadin (GAG IgA and AGA IgG) and the anti-endomysium (EMA IgA) as the screening test of anti-endomysium (EMA IgA) as the screening test of choice because of its accuracy. choice because of its accuracy.

• Most physicians do not know about this testMost physicians do not know about this test• Name is difficult to rememberName is difficult to remember• Expensive to do testExpensive to do test


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DiagnosisDiagnosis

• The IgA endomysial antibody immuno-The IgA endomysial antibody immuno-fluorescence (EMA) test is also fluorescence (EMA) test is also recommended as an equivalent screening recommended as an equivalent screening test by the National Institute of Health test by the National Institute of Health (2004). (2004).


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DiagnosisDiagnosis

• measurement of quantitative serum IgA should be taken measurement of quantitative serum IgA should be taken concurrently. concurrently.

• If the child has normal IgA serum levels and an elevated If the child has normal IgA serum levels and an elevated IgA antibody to human recombinant tissue IgA antibody to human recombinant tissue transglutaminase an intestinal biopsy should be scheduled transglutaminase an intestinal biopsy should be scheduled to confirm the diagnosis and determine the level of to confirm the diagnosis and determine the level of involvement in the small intestine.Intestinal biopsy should involvement in the small intestine.Intestinal biopsy should also be done in children with negative serological tests but also be done in children with negative serological tests but with failure to thrive, chronic diarrhea, or a diagnosis with with failure to thrive, chronic diarrhea, or a diagnosis with high incidence of celiac disease (NASPGHN, 2004). high incidence of celiac disease (NASPGHN, 2004).


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DiagnosisDiagnosis

• positive serology test and a negative small positive serology test and a negative small bowel biopsy may represent a false positive bowel biopsy may represent a false positive serology test or milder disease without serology test or milder disease without current changes in the small bowel (latent current changes in the small bowel (latent celiac disease). celiac disease).


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DiagnosisDiagnosis

• A positive serology test that reverts to A positive serology test that reverts to negative after compliance with a gluten free negative after compliance with a gluten free diet is considered supportive evidence diet is considered supportive evidence


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DiagnosisDiagnosis

• In situations where the diagnosis is In situations where the diagnosis is uncertain in a symptomatic child, HLA uncertain in a symptomatic child, HLA typing can be done, repeat small bowel typing can be done, repeat small bowel biopsy may be scheduled, or a trial on a biopsy may be scheduled, or a trial on a gluten free diet (GFD) can be instituted. gluten free diet (GFD) can be instituted.


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DiagnosisDiagnosis

• Dermatitis HerpetiformisDermatitis Herpetiformis• Diagnostic of Celiac DiseaseDiagnostic of Celiac Disease


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Barriers to DiagnosisBarriers to Diagnosis

• Variability of symptoms especially at different agesVariability of symptoms especially at different ages• Lack of education in publicLack of education in public• Lack of education in physiciansLack of education in physicians• Definitive test is not availableDefinitive test is not available• No drug treatmentNo drug treatment• Possible necessity of invasive procedure (small bowel Possible necessity of invasive procedure (small bowel

biopsy to diagnoses)biopsy to diagnoses)• Definative test is gluten free diet—difficult to each and to Definative test is gluten free diet—difficult to each and to

follow in patients who are not willing to learn about it.follow in patients who are not willing to learn about it.


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Illness Due to MalnutritionIllness Due to Malnutrition

• Low dental enamelLow dental enamel• Osteoporosis (40% decreased bone density)Osteoporosis (40% decreased bone density)• Short StatureShort Stature• Delayed PubertyDelayed Puberty• ArthritisArthritis• Hair lossHair loss• InfertilityInfertility• Recurrent spontaneous abortionRecurrent spontaneous abortion


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Autoimmune DiseaseAutoimmune Disease

• Growing recognition that Celiac Disease is Growing recognition that Celiac Disease is really a multi-system autoimmune disorder really a multi-system autoimmune disorder with many associated conditionswith many associated conditions


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• Distinct Neurological component that Distinct Neurological component that includes ataxia, epilepsy, neuropathiesincludes ataxia, epilepsy, neuropathies

• DementiaDementia• HeadachesHeadaches• Learning DisordersLearning Disorders• Developmental Delay in childrenDevelopmental Delay in children• Hypotonia in childrenHypotonia in children


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• Distinct Neurological component that Distinct Neurological component that includes ataxia, epilepsy, neuropathiesincludes ataxia, epilepsy, neuropathies

• Gluten ataxia (balance problems) may be Gluten ataxia (balance problems) may be only manifestation of celiac disease. May only manifestation of celiac disease. May have antibodies to perkinje cells of have antibodies to perkinje cells of cerebellum (Friedrich’s Ataxia Group, UK, cerebellum (Friedrich’s Ataxia Group, UK, 2001)2001)


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• Intestinal LymphomaIntestinal Lymphoma• Intestinal carcinomaIntestinal carcinoma


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• Autoimmune Thyroid DiseaseAutoimmune Thyroid Disease• Dermatitis HerpetiformisDermatitis Herpetiformis• Type 1 Diabetes Mellitus (1 in 12)Type 1 Diabetes Mellitus (1 in 12)• Rheumatoid ArthritisRheumatoid Arthritis• HypoparathyroidismaHypoparathyroidisma• Sjogrens DiseaseSjogrens Disease• IGA deficiencyIGA deficiency• IGA nephropathy (kidney disease)IGA nephropathy (kidney disease)• Downs SyndromeDowns Syndrome• Collagen Vascular Disorders (Lupus, MCVD)Collagen Vascular Disorders (Lupus, MCVD)


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• The autoimmune reaction to the toxic The autoimmune reaction to the toxic protein fraction of the gluten is variable protein fraction of the gluten is variable with some individuals having more damage with some individuals having more damage than others to the bowelthan others to the bowel

• The reaction attacks the villi of the small The reaction attacks the villi of the small intestineintestine


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TreatmentTreatment

• The only treatment currently available for celiac The only treatment currently available for celiac disease is strict adherence to a gluten free dietdisease is strict adherence to a gluten free diet

• Even small amounts of gluten regularly can result Even small amounts of gluten regularly can result in villi damage. in villi damage.

• The National Food Authority defines glutenfree The National Food Authority defines glutenfree foods as food with no gluten and foods with less foods as food with no gluten and foods with less than 200 ppm as low gluten (NASPGHN, 2004). than 200 ppm as low gluten (NASPGHN, 2004).


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TreatmentTreatment

• Gluten detection techniques are not always Gluten detection techniques are not always accurate and there is lack of solid scientific accurate and there is lack of solid scientific evidence for a threshold of gluten consumption evidence for a threshold of gluten consumption that causes harm (NASPGHN, 2004). that causes harm (NASPGHN, 2004).

• The American Dietetic Association has published The American Dietetic Association has published guidelines for dietary treatment of celiac disease guidelines for dietary treatment of celiac disease that are supported and used by most professionals that are supported and used by most professionals treating children with celiac disease (American treating children with celiac disease (American Dietetic Association, 2002). Dietetic Association, 2002).


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TreatmentTreatment

• Children who adhere to a GFD generally Children who adhere to a GFD generally have resolution of their gastrointestinal have resolution of their gastrointestinal symptoms, regain weight and stature if symptoms, regain weight and stature if diagnosed early, regain normal amounts of diagnosed early, regain normal amounts of red blood cells, and have improvement in red blood cells, and have improvement in their sense of physical and psychological their sense of physical and psychological well being (NASPGHN,2004). well being (NASPGHN,2004).


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TreatmentTreatment

• Cross contamination of foods can occur via Cross contamination of foods can occur via cooking or eating utensils so many families resort cooking or eating utensils so many families resort to a GFD for the entire household. to a GFD for the entire household.

• Cross contamination of foods can occur via Cross contamination of foods can occur via cooking or eating utensils so many families resort cooking or eating utensils so many families resort to a GFD for the entire household. Parents and to a GFD for the entire household. Parents and children trying to maintain a GFD must learn to children trying to maintain a GFD must learn to read all food labels for ingredients containing read all food labels for ingredients containing gluten, such as malt flavoring, food starches, and gluten, such as malt flavoring, food starches, and additives for bulk such as used in sausages or hot additives for bulk such as used in sausages or hot dogs dogs


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TreatmentTreatment

• Medications can also contain gluten as a Medications can also contain gluten as a binding agent, and even some lipsticks have binding agent, and even some lipsticks have been found to have gluten. been found to have gluten.


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TreatmentTreatment

• All families with the diagnosis of celiac All families with the diagnosis of celiac disease should meet with a dietitian to learn disease should meet with a dietitian to learn about reading food labels, common food about reading food labels, common food additives to avoid, and use of rice, soy, additives to avoid, and use of rice, soy, corn, or potato flour for cooking in the corn, or potato flour for cooking in the home. home.


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TreatmentTreatment

• Adolescents and children need to be educated Adolescents and children need to be educated about the foods they should avoid when eating about the foods they should avoid when eating outside the home. This can be particularly difficult outside the home. This can be particularly difficult for adolescents who want to conform to their peer for adolescents who want to conform to their peer group eating habits. group eating habits.

• Parents and providers can help children identify Parents and providers can help children identify common foods in restaurants that are gluten free common foods in restaurants that are gluten free or even call ahead to restaurants to talk with the or even call ahead to restaurants to talk with the food preparers to identify food choices that are food preparers to identify food choices that are acceptable so adolescents do not need to do this in acceptable so adolescents do not need to do this in front of their peers. front of their peers.


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TreatmentTreatment

• Referring families to a celiac support group is an Referring families to a celiac support group is an excellent way of providing information regarding excellent way of providing information regarding the condition and on maintaining a GFD. the condition and on maintaining a GFD.

• The internet also provides access to valuable The internet also provides access to valuable information from professional organizations information from professional organizations developed to help support individuals and families developed to help support individuals and families with celiac disease and commercial companies with celiac disease and commercial companies supplying gluten free foods and recipes supplying gluten free foods and recipes


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Treatment of Celiac DiseaseTreatment of Celiac Disease

• Celiac disease is serious. Fortunately you Celiac disease is serious. Fortunately you can control celiac disease just by not eating can control celiac disease just by not eating any gluten. By following the right diet, you any gluten. By following the right diet, you can reverse the damage caused by celiac can reverse the damage caused by celiac disease and you'll feel better. But if you disease and you'll feel better. But if you "cheat" on your diet, the damage will come "cheat" on your diet, the damage will come back, even if you don't feel sick right away. back, even if you don't feel sick right away.


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• You'll have to explain your problem and the You'll have to explain your problem and the gluten-free diet to your family members and ask gluten-free diet to your family members and ask for their support and help. It will take time for you for their support and help. It will take time for you and your family to learn how to avoid gluten in and your family to learn how to avoid gluten in your diet. You can contact one of the celiac your diet. You can contact one of the celiac support groups listed in the right column of this support groups listed in the right column of this handout. These groups are excellent sources of handout. These groups are excellent sources of information and advice. They'll help you find information and advice. They'll help you find gluten-free foods and good recipes, and give you gluten-free foods and good recipes, and give you tips for successfully living with celiac disease. tips for successfully living with celiac disease.


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• Celiac disease is treated by not eating gluten. This Celiac disease is treated by not eating gluten. This can be difficult because gluten is in many foods, can be difficult because gluten is in many foods, but a dietitian can help adjust a person's diet to cut but a dietitian can help adjust a person's diet to cut out gluten. It is important not to start a gluten-free out gluten. It is important not to start a gluten-free diet unless you are truly diagnosed with celiac diet unless you are truly diagnosed with celiac disease. Following a gluten-free diet allows the disease. Following a gluten-free diet allows the small intestine to heal. But that doesn't mean the small intestine to heal. But that doesn't mean the person can start eating gluten again. For someone person can start eating gluten again. For someone with celiac disease, gluten will always irritate their with celiac disease, gluten will always irritate their intestines and, if this happens, the diarrhea, intestines and, if this happens, the diarrhea, stomachaches, and other problems will return. stomachaches, and other problems will return.


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• If you're diagnosed with celiac disease, it If you're diagnosed with celiac disease, it can be a challenge to learn which foods can be a challenge to learn which foods contain gluten. You may not be able to contain gluten. You may not be able to remember them all, but you can keep a list remember them all, but you can keep a list with you, and ask about menu items at with you, and ask about menu items at restaurants before digging in. Before you restaurants before digging in. Before you know it, you'll be a pro at knowing which know it, you'll be a pro at knowing which foods are safe and which are not. foods are safe and which are not.


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• Here's a quick quiz:Here's a quick quiz:• Which of these foods contain gluten?Which of these foods contain gluten?• pizza pizza • fried chicken fried chicken • pasta pasta • If you said all three, you're right! Pizza was the easiest choice because If you said all three, you're right! Pizza was the easiest choice because

you know the crust is bread. But did you know that battered foods like you know the crust is bread. But did you know that battered foods like fried chicken and even some French fries contain gluten? Pasta also fried chicken and even some French fries contain gluten? Pasta also contains gluten because it is made from wheat. Luckily, you can make contains gluten because it is made from wheat. Luckily, you can make or buy gluten-free pizza crust, make fried chicken with a gluten-free or buy gluten-free pizza crust, make fried chicken with a gluten-free batter, and find gluten-free pasta and French fries. In fact, nearly all of batter, and find gluten-free pasta and French fries. In fact, nearly all of the foods we eat can be made gluten-free.the foods we eat can be made gluten-free.


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• In addition to foods that contain gluten, In addition to foods that contain gluten, you'll need to watch out for foods that may you'll need to watch out for foods that may have been contaminated with gluten. That have been contaminated with gluten. That means a food that doesn't contain gluten as means a food that doesn't contain gluten as an ingredient, but came into contact with an ingredient, but came into contact with gluten-containing foods. This is most likely gluten-containing foods. This is most likely to occur at home in your own kitchen. For to occur at home in your own kitchen. For instance, wheat bread crumbs in the toaster, instance, wheat bread crumbs in the toaster, the butter, or peanut butter the butter, or peanut butter


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• If you have celiac disease you will need your own If you have celiac disease you will need your own toaster and you should also have separate spreads toaster and you should also have separate spreads and condiments to avoid this cross-contamination. and condiments to avoid this cross-contamination. Some foods are contaminated during processing. Some foods are contaminated during processing. This is often what happens to oats. Oats do not This is often what happens to oats. Oats do not contain gluten, but many doctors and dietitians contain gluten, but many doctors and dietitians recommend avoiding them because they are milled recommend avoiding them because they are milled or processed in plants with wheat, rye, or barely or processed in plants with wheat, rye, or barely and therefore become contaminated. .and therefore become contaminated. .


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• The best approach is to read labels, but here The best approach is to read labels, but here are a few foods to steer clear of until you are a few foods to steer clear of until you can verify that they are gluten-free: can verify that they are gluten-free:

• packaged rice mixes packaged rice mixes • lunch meats lunch meats • sausages sausages • instant cocoa instant cocoa • canned soupscanned soups


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• SpeltSpelt


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• • All Patients With Osteoporosis May Benefit All Patients With Osteoporosis May Benefit

From Screening for Celiac DiseaseFrom Screening for Celiac Disease


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Long Term EffectsLong Term Effects

• Natural history of untreated, treated, and partially Natural history of untreated, treated, and partially treated celiac disease is unknown (Hill, 2003)treated celiac disease is unknown (Hill, 2003)

• Stunting of growth Stunting of growth • Profound effect on school performance and Profound effect on school performance and

quality of life (neurologic damage in children quality of life (neurologic damage in children may not be fully reversible)may not be fully reversible)

• Unknown if untreated diseases causes increased Unknown if untreated diseases causes increased risk of GI malignancies, or other diseasrisk of GI malignancies, or other diseas


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RestaurantsRestaurants

• OutbackOutback• Grolla Restaurant and Wine Bar,Grolla Restaurant and Wine Bar,

2930 NE Killingsworth St.2930 NE Killingsworth St.

Portland, OR 503-493-9521Portland, OR 503-493-9521


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Grain SuppliesGrain Supplies


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• Bob’s Red Mill Natural Foods expands Gluten Bob’s Red Mill Natural Foods expands Gluten Free Line with new mixesFree Line with new mixesBob's Red Mill has added two new gluten-free Bob's Red Mill has added two new gluten-free products – GF Brownie Mix and GF Pancake Mix products – GF Brownie Mix and GF Pancake Mix – to its successful Gluten Free line. Consumers – to its successful Gluten Free line. Consumers with celiac disease, wheat allergies and wheat with celiac disease, wheat allergies and wheat intolerances can now choose from a total of seven intolerances can now choose from a total of seven signature Gluten Free products as well as more signature Gluten Free products as well as more than 40 naturally gluten-free items – all backed by than 40 naturally gluten-free items – all backed by testing and identified by the symbol shown above testing and identified by the symbol shown above


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• Bob’s Red Mill stone grinds flours in a dedicated Bob’s Red Mill stone grinds flours in a dedicated room for the production of its gluten-free line and room for the production of its gluten-free line and performs batch testing before processing and after performs batch testing before processing and after packaging. The company adheres to the Codex packaging. The company adheres to the Codex Alimentarius standard – the international gluten-Alimentarius standard – the international gluten-free food standard for manufacturers. While the free food standard for manufacturers. While the current Codex gluten-free standard specifies a current Codex gluten-free standard specifies a gluten limit of 200 parts per million (ppm), Bob’s gluten limit of 200 parts per million (ppm), Bob’s Red Mill’s gluten-free products consistently fall Red Mill’s gluten-free products consistently fall below 20 ppm. below 20 ppm.


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• •

Organic Buckwheat Kernels (Roasted-Organic Buckwheat Kernels (Roasted-Kasha)Kasha)OrganicOrganic Creamy Buckwheat Creamy Buckwheat CerealCerealAlmondAlmond Meal/ Meal/FlourFlourAmaranthAmaranth FlourFlourAmaranthAmaranth GrainGrainArrowrootArrowroot StarchStarchBakingBaking PowderPowderBakingBaking SodaSodaBlackBlack Bean Bean FlourFlourBrownBrown Rice Rice FlourFlourBuckwheatBuckwheat GroatsGroats OrganicOrganicCornstarchCornstarchCreamyCreamy Brown Rice Brown Rice FarinaFarinaEnerEner-G Foods -G Foods CrackersCrackersEnerEner-G Foods Egg -G Foods Egg ReplacerReplacerEnerEner-G Foods Granola -G Foods Granola BarsBarsEnerEner-G Foods Pound -G Foods Pound CakeCakeEnerEner-G Foods White Rice -G Foods White Rice LasagnaLasagnaEnerEner-G Foods White Rice -G Foods White Rice MacaroniMacaroniEnerEner-G Foods White Rice -G Foods White Rice SpaghettiSpaghettiEnerEner-G Sesame Pretzel -G Sesame Pretzel RingsRingsFavaFava Bean Bean FlourFlourFlaxseedFlaxseedFlaxseedFlaxseed MealMealFlaxseedFlaxseed Meal ( Meal (Golden)Golden)GarbanzoGarbanzo Bean Bean FlourFlourGlutenGluten Free All Purpose Baking Free All Purpose Baking FlourFlourGlutenGluten Free Brownie Free Brownie MixMixGlutenGluten Free Chocolate Cake Free Chocolate Cake MixMixGlutenGluten Free Chocolate Chip Cookie Free Chocolate Chip Cookie MixMixGlutenGluten Free Free DietDietGlutenGluten Free Garbanzo and Free Garbanzo and FavaFava FlourFlourGlutenGluten Free Homemade Wonderful Bread Free Homemade Wonderful Bread MixMixGlutenGluten Free Mighty Tasty Hot Free Mighty Tasty Hot CerealCerealGlutenGluten Free Pancake Free Pancake MixMixGlutenGluten Free Sweet White Sorghum Free Sweet White Sorghum FlourFlourGlutenGluten-Free 101-Free 101Gluten-Free Gourmet Makes Gluten-Free Gourmet Makes DessertsDessertsGlutenGluten-Free Starter -Free Starter KitKitGoldenGolden Flaxseed, Flaxseed, OrganicOrganicGreenGreen Pea Pea FlourFlourGuarGuar GumGumHazelnutHazelnut Meal/ Meal/FlourFlourHulledHulled MilletMilletMilletMillet FlourFlourMilletMillet Grits/ Grits/MealMealOrganicOrganic Buckwheat Buckwheat FlourFlourOrganicOrganic Coconut Coconut FlourFlourOrganicOrganic Quinoa Quinoa FlourFlourPamela'sPamela's Chunky Chocolate Chip Chunky Chocolate Chip CookiesCookiesPamela'sPamela's Ginger Ginger CookiesCookiesPamela'sPamela's Peanut Butter Peanut Butter CookiesCookiesPamela'sPamela's Shortbread Swirl Shortbread Swirl CookiesCookiesPotatoPotato FlourFlourPotatoPotato StarchStarchQuinoaQuinoa Organic Organic GrainGrainRiceRice BranBranSweetSweet White Rice White Rice FlourFlourTapiocaTapioca FlourFlourTeffTeff ( (TefTef, , T'efT'ef) ) FlourFlourTeff (Tef, Teff (Tef, T'ef) Whole GrainTSPTVP® (Textured Vegetable Protein)Wheat Free Biscuit & Baking T'ef) Whole GrainTSPTVP® (Textured Vegetable Protein)Wheat Free Biscuit & Baking MixWhite Bean FlourWhite Rice FlourXanthan GumYeast, Active DryYeast, Nutritional T6635MixWhite Bean FlourWhite Rice FlourXanthan GumYeast, Active DryYeast, Nutritional T6635

•

Bob's Red Mill Natural Foods • 5209 SE International Way • Milwaukie, OR 97222Bob's Red Mill Natural Foods • 5209 SE International Way • Milwaukie, OR 97222Business Hours 8am – 5pm Monday-Friday (800) 349-2173 FAX (503) 653-1339 Business Hours 8am – 5pm Monday-Friday (800) 349-2173 FAX (503) 653-1339

http://www.bobsredmill.com/organic_info.php

http://www.bobsredmill.com/catalog/index.php?action=showdetails&product_ID=91






















































































































































































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ResourcesResources

• In the following cookbooks, the author, who has celiac disease herself, In the following cookbooks, the author, who has celiac disease herself, shares what she has learned about a gluten-free diet. Bette Hagman is shares what she has learned about a gluten-free diet. Bette Hagman is the author. The publisher is Henry Holt and Co.the author. The publisher is Henry Holt and Co.

• The Gluten-Free Gourmet: Living Well Without Wheat The Gluten-Free Gourmet: Living Well Without Wheat • More From the Gluten-Free Gourmet More From the Gluten-Free Gourmet • The Gluten-BibleThe Gluten-Bible• Waiter….is there Wheat in my Soup?Waiter….is there Wheat in my Soup?• The Gluten-Free Gourmet Cooks Fast and Healthy The Gluten-Free Gourmet Cooks Fast and Healthy • This book is a general guide to living gluten-free:This book is a general guide to living gluten-free:• Against the Grain: The Slightly Eccentric Guide to Living Well Against the Grain: The Slightly Eccentric Guide to Living Well

Without Gluten or Wheat, written by Jax Peters Lowell and published Without Gluten or Wheat, written by Jax Peters Lowell and published by Henry Holt and Co. by Henry Holt and Co.


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OrganizationsOrganizations

• Celiac Disease FoundationCeliac Disease Foundationhttp://http://www.celiac.orgwww.celiac.org 13251 Ventura Blvd., #113251 Ventura Blvd., #1Studio City, CA 91604Studio City, CA 91604818-990-2354818-990-2354

• American Celiac Society-Dietary Support American Celiac Society-Dietary Support CoalitionCoalition58 Musano Court58 Musano CourtWest Orange, NJ 07052West Orange, NJ 07052973-325-8837973-325-8837

http://www.celiac.org/

http://www.celiac.org/


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OrganizationsOrganizations

• Celiac Sprue AssociationCeliac Sprue Associationhttp://http://www.csaceliacs.orgwww.csaceliacs.org [email protected]@csaceliacs.org

• Gluten Intolerance Group of North AmericaGluten Intolerance Group of North America15110 10th Ave. SW, Suite A15110 10th Ave. SW, Suite ASeattle, WA 98166-1820Seattle, WA 98166-1820206-246-6652206-246-6652

http://www.csaceliacs.org/

http://www.csaceliacs.org/

mailto:[email protected]


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ReferencesReferences

• Detecting Celiac Disease in Your PatientsDetecting Celiac Disease in Your Patients ((American Family Physician American Family Physician March 1, March 1, 1998, 1998, http://www.aafp.org/afp/980301ap/pruessn.http://www.aafp.org/afp/980301ap/pruessn.htmlhtml) )

http://www.aafp.org/afp/980301ap/pruessn.html




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