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The Need for Gluten-Free · 12/18/2018 3 Intestinal Villi Dermatitis Herpetiformis Celiac sounds...
Transcript of The Need for Gluten-Free · 12/18/2018 3 Intestinal Villi Dermatitis Herpetiformis Celiac sounds...
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