The Need for Gluten-Free

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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.

1 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 2 1

2 Prevalence I can t eat that I m allergic to it... I follow a gluten-free diet. ~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 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 2

3 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 Peanuts Eggs Tree Nuts Wheat Shellfish Soybeans Fish *The other 10% is any number of other foods. 6 3

4 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) 4

Tip to Remember Allergies involve the immune system Can be acute and life-threatening However, no long-term consequences Intolerances / Sensitivities involve the GI

5 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 5

of two protein factions: Gliadin (a prolamin) Wheat =

Wheat + Rye Glutenin (a glutelin) Linking Gluten to

Eating gluten triggers an autoimmune reaction Body

6 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 6

7 Intestinal Villi Dermatitis Herpetiformis 7

8 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 8

9 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 9

starch Supplements Medications How much gluten is tolerated?

10 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 = 1/7000 th of a slice of wheat bread equates to the less than 20 ppm gluten 10

11 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 11

12 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 12

13 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] 25 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 13

14 Wheat Allergy No: Wheat Triticale (Wheat + Rye) Generally tolerated grains: Aramanth Barley Buckwheat Corn Millet Oats Quinoa Rice / Wild Rice Rye Sorghum 14

15 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 Immune Response HLA (the genetic testing) HLA DQ2/8 restricted (~97% positive) Not HLA DQ2/8 restricted (50% positive) Not HLA DQ2/8 restricted 35-40% positive) Autoantibodies Almost always present Always absent Always absent Enteropathy (inflammation of GI tract) Symptoms Almost always present Always absent Always absent Both intestinal and extra intestinal (indistinguishable from GS & WA with GI symptoms) Both intestinal and extra intestinal (indistinguishable from 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 29 Gluten-Related Disorders Pathogenesis Autoimmune Allergic Not Autoimmune Not Allergic (Innate Immunity) Celiac Disease Gluten Ataxia Dermatitis Herpetiformis Wheat Allergy Gluten Sensitivity Symptomatic Silent Potential Respiratory Allergy Food Allergy Wheat Dependent Exercise Induced Anaphylaxis Contact Urticaria Adapted from the book Gluten Freedom by Alessio Fasano, MD 30 15

Ingredients in packaged products may change without warning. Check ingredient statements every time you shop/purchase. If in doubt call the manufacturer.

16 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 16

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

17 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 17

18 Reminders Avoid Cross Contact Separate storage, prep areas, utensils Train staff Consider vulnerable patients/residents Report incidences Resources / References Celiac Disease Foundation The Gluten Intolerance Group National Foundation for Celiac Awareness Celiac Sprue Association Gluten Free Drugs Gluten Free Watch Dog Apps Find Me Gluten Free Identifies eateries with GF options Triumph Dining Cards Print & App Various cuisine & languages Explains GF diet o o Gluten Freedom. Alessio Fasano, MD Wiley New York, New York. Celiac Disease Nutrition Guide. Third Edition Tricia Thompson, MS, RD AND 18

19 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 MONITOR TYPICAL NUMBER OF PARTICIPANTS NUMBER OF PARTICIPANTS NOTES Preclinical Testing of drug in nonhuman subjects, to gather efficacy, toxicity and pharmacokinetic information unrestricted A graduate level researcher (Ph.D.) not applicable (in vitro and in vivo only) Phase 0 Pharmacokinetics particularly oral bioavailability and halflife of the drug very small, subtherapeutic clinical researcher 10 people often skipped for phase I Phase I Testing of drug on healthy volunteers for dose-ranging determines whether often subtherapeutic, but with ascending doses clinical researcher drug is safe to check for efficacy Phase II Testing of drug on patients to assess efficacy and safety therapeutic dose clinical researcher 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 dose clinical researcher and personal physician determines a drug s therapeutic effect; at this point, the drug is presumed to have some effect Phase IV Postmarketing surveillance watching drug use in public therapeutic dose personal physician anyone seeking treatment from their physician watch drug s long-term effect 19

This presentation is intended to provide general information about

20 Your Special Diet Partner Thank you for participating in today s session! 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 39 Post - Test 20

21 Is this gluten free? Fiesta Lime Chicken Grilled chicken done fiesta-style with zesty lime sauce, Mexiranch and Jack-cheddar. Served with crisp tortilla strips, seasoned rice and freshly-made pico de gallo. What questions would you have before you ordered? Where is the Wheat? BREAKFAST ORANGE JUICE CEREAL OF CHOICE BAKED EGG OMELET TOAST MARGARINE JELLY COFFEE/SUGAR/CREAMER /MILK LUNCH ITALIAN CRUSTED FISH SOUR CREAM MASHED POTATOES SEASONED PEAS BREAD / MARGARINE RASPBERRY PARFAIT SQUARE COFFEE/SUGAR/CREAMER/MILK GARNISH LEMON WEDGE SLICED TURKEY KEY LARGO VEGETABLES Hint: You should find 7-8 suspect menu items 42 21

Gluten Sensitivity Fact from Myth. Disclosures OBJECTIVES 18/09/2013. Justine Turner MD PhD University of Alberta. None Relevant

Gluten Sensitivity Fact from Myth Justine Turner MD PhD University of Alberta Disclosures None Relevant OBJECTIVES Understand the spectrum of gluten disorders Develop a diagnostic algorithm for gluten