Nicole Cerillo, RD Kogan Celiac Center

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1 Nicole Cerillo, RD Kogan Celiac Center

2 The Kogan Celiac Center is designed to address the lifestyle changes associated with living well with celiac disease. Intended to be a complement to and an extension of existing physician services o Periodic screenings o Patient education o Professional education o Community outreach

3 What is gluten, where is it found? Why go gluten free? Stages of going gluten free Naturally gluten free tips Q&A session

4 Gluten is a general name for storage proteins: o Wheat = gliadin o Rye = secalin o Barley = hordein o Oats = avenin o Rice = oryzenin o Corn = zein Cures for CD in progress o Pill o Zonulin GFD only treatment at present

5 Celiac disease is a systemic immune-mediated disorder caused by a permanent sensitivity to gluten in genetically susceptible individuals.

6 Genetics Gluten Necessary Causes Pathogenesis? Gender Infant feeding Infections Others Risk Factors Celiac disease

7 Is a common disease Caused by an inappropriate immune response to gluten Can manifest in many different clinical presentations ( A Clinical Chameleon ) The mainstay of diagnosis remains a small bowel biopsy followed by clinical remission after gluten free diet Gluten free diet remains the cornerstone of treatment Untreated cases carry risk for growth failure, osteoporosis, infertility, psychiatric and behavioral disorders and cancer

8 Celiac disease affects 2 million Americans Epilepsy affects 2.8 million Americans Alzheimer s affects 2 million Americans Ulcerative Colitis affects ½ million Americans Multiple sclerosis affects 333,000 Americans Cystic Fibrosis affects 30,000 Americans

9 Type 1 Diabetes Mellitus: % Thyroiditis: 4-8% Arthritis: % Autoimmune liver diseases: 6-8% Sjögren s syndrome: 2-15% Idiopathic dilated cardiomyopathy: 5.7% IgA nephropathy: 3.6%

10 Short-term Long-term (if left untreated) Diarrhea or loose stools Nausea Change in bowel habits Abdominal pain Bloating Gas Migraines & headaches Failure to thrive Skin rash (Dermatitis Herpetiformis) Irritability Anxiety Extreme fatigue Joint pain & inflammation Iron deficiency Missed menstral perods Numbness and tingling Dental enamel defects Weight loss Delayed weight gain growth, and retardation in children Depression Chronic fatigue Anemia Discolored teeth Infertility Vitamin D, K, & B-12 deficiency Malnutrition Neurological disorders Seizures Osteoporosis Cancer

Diagnostic principles Confirm diagnosis before treating o Diagnosis of Celiac Disease mandates a strict gluten-free diet for life following

11 Diagnostic principles Confirm diagnosis before treating o Diagnosis of Celiac Disease mandates a strict gluten-free diet for life following the diet is not easy QOL implications Failure to treat has potential long term adverse health consequences increased morbidity and mortality

12 Consultation with a skilled dietitian Education about the disease Lifelong adherence to a gluten free diet Identification & treatment of nutritional deficiency Access to an advocacy group Continuous long-term follow-up by a multidisciplinary team

13 Celiac, non-gluten sensitivity, gluten intolerance, gluten related diseases (ie. Autoimmune disorders) 1. Avoiding known wheat & gluten containing foods 2. Gluten free label reading 3. Zero Tolerance gluten free diet 1. Recovery period 2. Obvious gluten 3. Trace gluten 4. Hidden gluten 4. Gluten Contamination 5. Molecular Mimicry 1. Gluten 2. Dairy 3. Oats 4. Soy

14 Avoid Wheat, rye, barley, triticale, and oats Instead, choose Grains: Amaranth, arrowroot, buckwheat, millet, quinoa, rice, sorghum, taro, and teff Starchy vegetables: Corn, popcorn, potato, beans, peas, and lentils Nut based flours Variations of the above grains, such as spelt, kamut, bulgur, faro, malt, couscous, farina, seitan, semolina, matzah, and tabbouleh See above Breads, pastas, cakes, cookies, and pastries made from these grains Breads, cakes, and pastries made from the above carbohydrates and specified gluten free Beer made from above grains, those containing caramel coloring (wine coolers), and malt beverages Gluten free beer (often made from sorghum), wine, brandy, champagne, cognac, distilled spirits, gin, rum, scotch whisky, tequila, and vodka

16 Zero Tolerance Gluten Free Diet 1. Recovery period 2. Obvious gluten 3. Trace gluten 4. Hidden gluten

17 Always wash hands, cutlery, utensils, pots, and pans thoroughly before preparing gluten free foods Grills and barbeques are common sources of contamination due to grill baste and sauces used to grill foods. Grills should be heated first, scraped, and cleaned before cooking gluten free Many restaurants use the same oil to cook products that may have had a breaded coating. Even though a food may be gluten free, be sure to check with your server and Chef to make sure separate oil is used in frying Items such as peanut butter, jam, mayonnaise, and all condiments in jars may be contaminated if used to spread on different foods that contain gluten. Always label condiments as gluten free only so everyone is aware the condiment is to be used on those products only Flours containing gluten have a tendency to stay airborne for a while after use. Wait at least one hour after using regular flour to start preparing gluten free foods in the kitchen. *This is KEY in pizza restaurants!

18 Many restaurants now have separate gluten free menus Call ahead and do your homework! Visit the webpage online first and look through the menu Be kind and ask for assistance early. Tell the server someone in your family you are dining with has CELIAC disease (NOT a gluten allergy) and cannot eat any gluten Ask about cross contamination. Get a chef or manager involved Use a GF dining card When in doubt DON T dine out

19 Toaster or Toaster Oven Flour Sifter Pasta Pot Pizza Paddle Cutting Boards Rolling Pins Non-Stick & Cast-Iron Pans Baking Sheets/Pans & Muffin Tins Mixing Spoons & Spatulas Baking Bowls Colanders *Be sure to have a separate cupboard and/or drawer in your kitchen labeled gluten free only to avoid these items being contaminated by mistake. Make sure everyone in your family is aware of these separate utensils for gluten free use only!

20 Which food does NOT contain gluten?

21 Veggie Burger (No Bun) Beef Burger (No Bun) Red Licorice Plain Toffee Hollandaise Sauce Teriyaki Sauce

22 Spelt Buckwheat Stone Ground Mustard Malt Vinegar Scalloped Potatoes Risotto

23 Molecular Mimicry o Medical theory that proteins in gluten, dairy, soy, and oats all have the same molecular structure o Tripeptide sequence o Identical to molecular structure in human immune tissue

25 GLUTEN DAIRY SOY OATS

26 Relapse Linked autoimmune conditions Gluten sensitivity & intolerance Irritable bowel syndrome 3 month elimination at a time Add back in 2x/week (consecutive days) to trial

27 Replace flour with almond meal Nut flours are a great way to replace flour and increase fiber and protein in recipes. Try also using ground nut meal in place of breadcrumbs and flour to coat meat or for baked goods. Grate raw cauliflower in place of steamed couscous, tabouli, or rice This is a great way to save time and increase your veggies! Add the same ingredients and spices you would to rice and you have a delicious low carb and grain free side.

Try lettuce wraps instead of bread For those who love sandwiches and wraps, try washed

28 Zucchini your noodles For an alternative to spaghetti or other pastas, roast finely sliced zucchini and serve with your favorite pasta sauce: tomato & basil, garlic & oil, pesto, etc. Try lettuce wraps instead of bread For those who love sandwiches and wraps, try washed lettuce (iceberg or butter lettuce works the best) to wrap your fillings. The possibilities are endless!

Make thin omelets instead of pizza bases Pizza is tough to replace but try making a very thin egg omelet (leaf round and cook well done in a nonstick pan and top with your favorite pizza toppings.

29 Make thin omelets instead of pizza bases Pizza is tough to replace but try making a very thin egg omelet (leaf round and cook well done in a nonstick pan and top with your favorite pizza toppings. Add on a grill for a few minutes for a crispy crust taste. Serve your burgers without a bun This trick has been around forever and it is probably the easiest (and most cost effective) way to minimize gluten naturally while eating out. Enhance the nutrition by adding healthy toppings instead such as lettuce, tomato, onion, avocado, and cucumbers.

Use a portabella mushroom in place of a bun This is delicious and nutritious! Just roast or grill two large field or portabella mushrooms until tender. Use these exactly as you would a hamburger bun.

30 Use a portabella mushroom in place of a bun This is delicious and nutritious! Just roast or grill two large field or portabella mushrooms until tender. Use these exactly as you would a hamburger bun. Use pureed cauliflower instead of polenta Pureed cooked cauliflower is a great alternative to polenta or corn meal (and helpful for those with a corn allergy too). Add sautéed vegetables, spices, olive oil, and lean chicken to create a healthy stir fry.

Use a tiny piece or raw chocolate in place of sweet treats Yes, have some chocolate! Dark chocolate (especially with a high cocoa content around 70%) is high in magnesium and antioxidants.

31 Use a tiny piece or raw chocolate in place of sweet treats Yes, have some chocolate! Dark chocolate (especially with a high cocoa content around 70%) is high in magnesium and antioxidants. This will help satisfy your sweet tooth and can prevent you from turning to pastries and cakes. Just remember, moderation is key! Choose wine over beer Studies show that a 5oz glass of wine three days per week can actually have a beneficial effect on the heart. Wine is not only grain free but it is lower in carbohydrates than beer. Red wine in particular is high in antioxidants and contains resveratrol which helps to scavenge free radicals and prevent against certain types of diseases.

32 Questions About Celiac Disease or Going Gluten Free? Call the Kogan Celiac Center Know someone who wants to join the Celiac support group? Send me an with the persons contact address

What is celiac disease?

What is celiac disease? Celiac disease is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate gluten,