Brought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library
Webinar Title: Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet: What Every Nutrition Professional Needs to Know
Description: Celiac disease is an inherited autoimmune disorder affecting 1-2% of the population. An increased prevalence of celiac disease is seen in other associated disorders such as Type 1 diabetes, autoimmune thyroid and liver diseases, Sjogren’s syndrome and Down syndrome.
Non-celiac gluten sensitivity (NCGS) is another condition thought to be triggered by the ingestion of gluten, although other components in wheat and FODMAP carbohydrates also have been implicated. Due to conflicting research, the lack of diagnostic biomarkers, and overlapping symptoms with celiac disease and IBS, the true prevalence of NCGS is unknown. In addition, it has been found that some individuals with NCGS actually may have undiagnosed celiac disease.
Nutrition professionals need to stay abreast with the latest research about these gluten related disorders in order to effectively manage this growing population. This session will provide evidence-based and practical information about celiac disease and NCGS, including clinical presentations, diagnosis, dietary management; North American gluten-free labeling regulations; nutritional quality and safety of gluten-free products; and client education resources.
Course Objectives: After completing this continuing education course, nutrition professionals should be able to: 1. Identify symptoms and discuss diagnostic challenges in order to differentiate between celiac disease and non-celiac gluten sensitivity. 2. List associated conditions with a high risk for celiac disease. 3. Describe the gluten-free diet including grains/foods allowed and to avoid. 4. Explain the dietary management strategies for celiac disease and non-celiac gluten sensitivity. 5. Discuss the key components of gluten-free labeling regulations and their impact on client education. 6. List key resources and products for clients.
Audience: Registered Dietitians (RD), Registered Dietitian Nutritionists (RDN), Dietetic Technicians Registered (DTR), Nutrition and Dietetic Technicians Registered (NDTR) and members of the interdisciplinary team
Brought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library
Course Continuing Professional Education (CPE) Hours: 1.5 CDR Level: 2
Suggested Learning Needs Codes: 3000: Nutrition Assessment 5000: Medical Nutrition Therapy 5110: Allergies, Sensitivities, Intolerances 5220: Gastrointestinal Disorders
Performance Quality Indicators 8.3.1 – Maintains the knowledge and skill to manage a variety of disease states and clinical conditions 8.3.6 – Keeps abreast of current nutrition and dietetics knowledge and trends 8.4.4 – Considers customers choice, beliefs, food sensitivities, allergies, wants and needs 10.1.3 – Works collaboratively with the interdisciplinary team (including NDTRs) to identify and implement valid and reliable nutrition screening to support access to care
Instructions for Obtaining Continuing Professional Education (CPE): Becky Dorner & Associates is a Continuing Professional Education (CPE) Accredited Provider (NU004) with the Commission on Dietetic Registration (CDR). CDR Credentialed Practitioners will receive 1.5 Continuing Professional Education units (CPEUs) for completion of this activity/material. To obtain the CPE Certificate, each participant must complete a simple evaluation and pass a short test (a grade of 70% is required). You can re-take the test as many times as needed. If you are interrupted and cannot finish the test, simply save the test and come back later to finish it. If you wish, you may also submit evaluations of the quality of activities/materials on the CDR Website at www.cdrnet.org.
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Brought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library
Speaker: Shelley Case, BsC, RD is a leading international expert on the gluten-free diet. Shelley is a registered dietitian, author, speaker and consultant with more than 30 years’ experience. She is a member of the Medical Advisory Boards of the Celiac Disease Foundation and Gluten Intolerance Group in the United States; Professional Advisory Council of the Canadian Celiac Association; and serves on the Scientific Advisory Board of the Grain Foods Foundation. Shelley has been featured on radio and television including NBC’s Today show, CBC, CTV and Global TV, as well as frequently quoted in major print media such as the Wall Street Journal, WebMD,
National Post, Globe and Mail, Food Business News, Chatelaine and Canadian Living. A popular speaker, she delivers presentations at medical, nutrition, celiac and food industry conferences throughout North America. Shelley’s best-selling book is highly recommended by health professionals, celiac organizations, consumers and the food industry. Author of many journal articles on celiac disease and the gluten-free diet, she also contributes to a variety of other publications for health professionals and consumers. Her column “Ask the Celiac Expert” is featured in Allergic Living magazine. In recognition of Shelley’s major contributions to the field of celiac disease and her dedication to educating health professionals an individuals with celiac disease in North America, she was awarded the Queen Elizabeth Golden Jubilee Medal. Shelley graduated with a Bachelor of Science Degree in Nutrition and Dietetics from the University of Saskatchewan and completed her Dietetic Internship at the Health Sciences Center in Winnipeg, Manitoba. Over the past 34 years, Shelley has helped thousands of people improve their eating habits and manage a variety of disease conditions through good nutrition. She is founder and president of Case Nutrition Consulting, Inc., a company specializing in celiac disease and the gluten-free diet. Professionally, Shelley is a member of the Dietitians of Canada, Saskatchewan Dietitians Association and the Academy of Nutrition and Dietetics (U.S.), as well as the Nutrition Entrepreneurs, Dietitians in Business and Communications, Food and Culinary Professionals and the Medical Nutrition Practice Groups of the Academy of Nutrition and Dietetics. When she is not sharing her nutrition and health expertise, Shelley is very active in her community and church. She is an accomplished musician who enjoys playing piano and keyboard in her church, at special events and for other occasions. She lives with her husband and daughter in Regina, Saskatchewan, Canada.
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 1
Today’s Webinar
Audio and Webinar Please refer to handout for instructions.
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The program will last approximately 90 min.
Credit Hours: Please refer to your handouts for detailed
information on about credit hours.
Shelley Case, RD
Leading international nutrition expert on celiac disease and the gluten-free diet
Popular speaker and educator, Articles have appeared in many
medical journals, magazines, other publications
She has been featured on radio and television including NBC’s Today show and frequently quoted in major print media
Honors: Queen Elizabeth Golden Jubilee Medal
Financial Disclosure
Author and publisher Gluten Free: The Definitive Resource Guide
Scientific Advisory Board Grain Foods Foundation
Celiac Expert Columnist Allergic Living Magazine
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:
What Every Nutrition Professional Needs to Know
Shelley Case, RD
Medical Advisory Board:Celiac Disease Foundation
Gluten Intolerance Group of North America
Professional Advisory Council:Canadian Celiac Association
Scientific Advisory Board:Grain Foods Foundation
Author and PublisherGluten Free: The Definitive Resource Guide
Session Highlights
Celiac Disease & Non-Celiac Gluten Sensitivity Gluten-Free Diet Safety of Gluten-Free Foods/Products Cross Contamination Gluten-Free and Food Allergen Labeling Gluten Threshold Levels Nutritional Quality of Gluten-Free Foods Potential New Therapies for Celiac Disease Resources
5Shelley Case, RD 6Shelley Case, RD
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 2
Gluten-Free Diet Boom
Latest Fad
Medical Necessity
Celiac Disease
Non-Celiac Gluten Sensitivity (NCGS)
7Shelley Case, RD
Celiac Disease
Affects 1–2% general population, especially Europe, North & South America, Australia
Also common in North Africa, Middle East and South Asia
Can develop at any age including the elderly
Estimated that only 5-15% diagnosed
Many misdiagnosed and/or delay in diagnosis
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Celiac Disease Inherited autoimmune intestinal disorder
Consumption of gluten triggers an immune reaction
Damage to the small intestinal villi
* Increased intraepithelial lymphocytes (IELs)
* Increased crypt hyperplasia
* Villous atrophy
9Shelley Case, RDCourtesy: Dr. Mohsin Rashid
Normal Celiac Disease
Celiac Disease Multi-system, multi-symptom disease
Results in a wide variety of symptoms and complications if gluten is not completely and permanently eliminated from the diet
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Gastrointestinal Abdominal pain, bloating, gas
Heartburn or acid reflux
Nausea, vomiting
Diarrhea (mild-severe)
Constipation
Diarrhea/constipation
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Nutritional Deficiencies
Iron, Folate, Vitamin B12
Calcium, Vitamin D
Other nutrients
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Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 3
Musculoskeletal
Dental enamel defects
Short stature
Osteoporosis
Bone and joint pain
Arthritis
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Common in children who develop celiac symptoms before age 7
Exact mechanism not clear
immune-mediated damage
nutritional disturbances
Enamel defects vary
color of enamel looks flat (not glazed)
single or multiple cream, yellow or brown opacities
rough enamel surface, horizontal grooves, shallow pits
Dental Enamel Defects
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Dental Enamel Defects
Oral manifestations of celiac disease: A clinical guide for dentists. Rashid M, et al. J Can Dent Assoc 2011
Classifications of Systemic Dental Enamel Defects in Celiac Disease
Grade 1 Defects in colour of enamel:single or multiple cream, yellowor brown opacities
Grade II Slight structural defects: rough enamel surface, horizontal grooves, shallow pits
Grade III Evident structural defects: deep horizontal grooves, large vertical pits
Grade IV Severe structural defects: shape of the tooth may be changed
Grade IDrs. Ted Malahias & Peter Green
Grade IIDrs. Ted Malahias & Peter Green
Grade IIIChildren’s Digestive Health and Nutrition Foundation
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Short Stature 10-15% of short children and teens have evidence
of celiac disease
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Cutaneous
Mouth Ulcers Dermatitis Herpetiformis
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Courtesy: NASPGHAN
Courtesy: NASPGHAN
Dermatitis Herpetiformis
Only minority (10%) have GI symptoms (mild) 65-75% have small intestinal villous atrophy May also present with other manifestations,
associated disorders and complications (autoimmune diseases, anemia, osteoporosis, malignancy)
Diagnosis - skin biopsy from unaffected skin next to blisters/erosions
Small intestinal biopsy not necessary
Treatment: Strict gluten-free diet for life Dapsone (short term)
18Shelley Case, RD
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 4
Neurological
Epilepsy
Ataxia
Peripheral neuropathy
Migraine headache
Depression
Behavioral changes
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Reproductive System
Delayed puberty
Menstrual irregularities
Infertility (women and men)
Miscarriage
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Other Presentations
Weight loss (but not always)
CD can occur in overweight or obese individuals
Elevated transaminases
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Clinical Presentations of CD
Symptoms can occur singly or in combination
Vary markedly with age of patient, the duration and extent of disease
Many newly diagnosed adults
DO NOT present with gastrointestinal symptoms
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Associated Conditions with Increased Risk for Celiac Disease
Autoimmune Diseases
Type 1 diabetes
Autoimmune thyroid disease
Autoimmune liver disease
Sjögren Syndrome
Arthritis
IgA nephropathy
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Other Disorders
Down Syndrome
Turner Syndrome
Selective IgA Deficiency
Relatives (1st degree)
2-15%
Shelley Case, RD
Complications of Undiagnosed or Untreated Celiac Disease
Bone disease
Associated health problems related to malnutrition and malabsorption
Increased risk of developing other autoimmune diseases
Increased risk of Non-Hodgkin lymphoma
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Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 5
25Shelley Case, RD 26Shelley Case, RD
Diagnosis ofCeliac Disease
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Diagnosis
Serological Screening Tests
Small Intestinal Biopsy
Must be on a gluten-containing diet
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Serological Screening Tests
IgA tTG (Tissue Transglutaminase)
IgA EMA (Endomysial Antibody)
IgG DGP (Deamidated Gliadin Peptide Antibody)
Total IgA level
* Selective IgA deficiency is more common in
celiac disease than general population
29Shelley Case, RD
Serological Screening
IgA level
*1 to 2% of patients with celiac disease are IgAdeficient compared to general population (0.17%)
30Shelley Case, RD
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 6
Reasons for False Negative Celiac Serology Tests
Age < 2 years
Selective IgA deficiency
Reduction or elimination of gluten
Use of corticosteroids or immunomodulator drugs
Possible laboratory error
31Shelley Case, RD
Marsh 0 Normal
Marsh 1-Infiltrative≥25 IEL/100 epithelial cells
Intraepithelial lymphocytosis
Marsh 2- HyperplasticInflammation/villous blunting
Marsh 3aVillous atrophy- Partial
Marsh 3bVillous atrophy - Subtotal
Marsh 3cVillous atrophy - Total
Small Intestinal Biopsy
32Shelley Case, RDCourtesy of NASPGHAN
Biopsy Samples
Need a minimum of 4-8 samples
3-4 distal duodenum and 1-3 from duodenal bulb
At least one sample from duodenal bulb increases detection rates in children and adults
Rates of diagnosis continue to increase for every additional biopsy sample taken
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Kurien M, et al. Gastrointestinal Endoscopy 2012Lebwohl B, et al. Gastrointestinal Endoscopy 2011Rashid M, et al. BMC Gastroenterol 2009
Small Intestinal Biopsy
Must be on a gluten-containing diet
If gluten is eliminated or restricted, serological and biopsy tests may be falsely negative
Sensitivity of serology & biopsy diminishes with increased duration on GFD
Gluten challenge (GC)
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Gluten Challenge
Quantity of gluten required and length of time?
No consensus – various protocols
2-5 slices of bread/day for 2 weeks to several months
One slice of bread ranges from 1.5-2.5 g gluten
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Kinetics of the histological, serological and symptomatic responses to gluten challenge in adults
with coeliac disease
Leffler, et al. Gut 2013
20 adults with biopsy-proven CD
Well controlled on a GFD for at least 12 months with no symptoms
Given either 3 or 7.5 grams of gluten/day (2 or 5 slices of bread) for 14 days
Duodenal biopsies (2 weeks prior to GC; Day 3 & 14)
Serological testing (2 weeks prior to GC, Day 0, 3, 7, 14, 28)
Genetic Testing
36Shelley Case, RD
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 7
2 pts on 7.5g gluten/day developed severe GI symptoms and had to reduce amount of gluten
Results
Significant reduction in Vh:Cd and ”increase” in IEL’s from baseline to day 14
Antibody levels “increased” slightly from baseline to day 14 but markedly by day 28
GI symptoms increased significantly by day 3 No differences seen between 2 gluten doses
\
Kinetics of the histological, serological and symptomatic responses to gluten challenge in adults with coeliac disease
Leffler, et al. Gut 2013
37Shelley Case, RD
Conclusions
14 day GC ≥ 3g gluten/day induces histological & serological changes in over 75% of adults with CD
Celiac antibody response is delayed in comparison with measurable histological changes
Celiac levels continue to rise significantly after the end of gluten challenge
Because no differences seen between 3 and 7.5 g of gluten/day suggests high gluten dose not routinely needed – therefore reduce acute symptoms of GC
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Leffler, et al., Gut 2013
Shelley Case, RD
Gluten Challenge
Leffler study small in size; sensitivity to gluten exposure varied greatly between individuals; and some had no significant serological or histological deterioration after 14 days of gluten exposure
At 4 weeks ~30% did not show measurable serology outcomes for CD
Leffler and others (e.g., Oxentenko & Murray ClinGastro Hepatol 2015) agree that a longer GC period (e.g., 8 weeks) may be necessary to induce serological and histological changes
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Leffler, et al., Gut 2013
Shelley Case, RD
Genetic Tests
HLA alleles associated with CD
DQ2 found in 95% of celiac patients
DQ8 found in remaining patients
DQ2/DQ8 found in 30-40% of general population
High negative predictive value to rule out CD
Negativity for DQ2/DQ8 excludes the diagnosis of celiac disease with 99% confidence
40Shelley Case, RD
Genetic Testing
How to test Cheek swab or blood test
Who to test Close relatives of patients with confirmed CD wanting to
know if they are at risk of developing CD Individuals already on a gluten-free diet Equivocal histology and serology findings in which a
negative genetic test would make CD highly unlikely How often to test
Once in a lifetime Diet
Gluten-free diet will not affect test result
41Shelley Case, RD
Celiac Disease
Strict life-long gluten-free diet currently is the ONLY treatment
Gluten-free diet is very complex
Consultation with a Registered Dietitian with expertise in celiac disease and the gluten-free diet
42Shelley Case, RD
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 8
Non-Celiac Gluten Sensitivity (NCGS)
Case report of 43 yr old woman
“Non-coeliac gluten sensitivity?” Ellis A. Lancet 1978
Few reports 1980-2008
Many studies published 2009-2016
3 international consensus conferences to address NCGS
43Shelley Case, RD
Sapone A, et al. BMC Med 2011Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: Celiac disease and gluten sensitivity.
Biesiekierski J, et al. Gastroenterol 2011Gluten causes gastrointestinal symptoms in subjects without celiac disease: A double-blind randomized placebo-controlled trial.
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Sapone A, et al. BMC Med 2012Spectrum of gluten-related disorders: Consensus on new nomenclature and classification.
Biesiekierski J, et al. Gastroenterology 2013No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed short-chain carbohydrates.
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Catassi C, et al. Nutrients 2015 Diagnosis of non-celiac gluten sensitivity (NCGS): The Salerno experts’ criteria.
Carroccio A, et al. Am J Gastroenterol 2012Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: Exploring a new clinical entity.
46Shelley Case, RD
Molina-Infante J, et al. Aliment Pharmacol Ther 2015 Systematic review: Noncoeliac gluten sensitivity.
Molina-Infante J, et al. Clin Gastroenterol Hepatol2017Suspected Nonceliac Gluten Sensitivity Confirmed in Few Patients After Gluten Challenge in Double-Blind Placebo-Controlled Trials
De Giorgio R, et al. Gut 2016Sensitivity to wheat, gluten and FODMAPS in IBS: facts or fiction?
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Non-Celiac Gluten Sensitivity (NCGS)
It is possible to be gluten intolerant and not have celiac disease
Non-autoimmune, non-allergic reaction to gluten
Many symptoms overlap with other conditions
48Shelley Case, RD
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 9
Overlapping GI Symptoms
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Overlapping GI and Extra-Intestinal Symptoms
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Non-Celiac Gluten Sensitivity (NCGS)“Melting Pot” of Different Patient Groups
Gluten sensitivity
Early-stage celiac disease: “celiac lite”
Misdiagnosed celiac disease
FODMAP intolerance
Other factors?
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Non-Celiac Gluten Sensitivity (NCGS)
Center for Celiac Research in Baltimore - Dr. AlessioFasano
Saw 5896 patients between 2004-2010 347/5896 patients - 6% fulfilled criteria for NCGS Symptoms
Abdominal pain (68%) Eczema and/or rash (40%) Headache (35%) “Foggy mind” (34%) Fatigue (33%) Diarrhea (33%) Depression (22%) Anemia (20%) Numbness legs/arms/fingers (20%) Joint pains (11%)
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Non-Celiac Gluten Sensitivity (NCGS)
Negative CD serology (TTG or EMA)
IgA deficiency ruled out
AGA antibodies may be positive
HLA DQ2 or DQ8 may be present
Intraepithelial lymphocytosis without villous atrophy
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Intraepithelial Lymphocytosis Increased lymphocytes in villous epithelial lining
Number of IEL’s can increase due to variety of immunologic stimulants: Gluten related disorders (CD, NCGS, wheat allergy) Non-gluten food hypersensitivity (e.g., cow’s milk, soy) Drugs (e.g., NSAID’s, PPI’s) Infections (e.g., H. pylori, Giardia) Bacterial overgrowth IBD Lymphocytic and collagenous colitis Immune dysregulation (e.g, RA, Graves, Hashimoto’s
thyroiditis, Lupus, MS) IBS
54Shelley Case, RDLauwers G, et al. Modern Pathology 2015
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 10
Food For Thought…
Non-Celiac Gluten Sensitivityvs
Celiac Disease
55Shelley Case, RD
Characterizations of Adults with a Self-Diagnosis of Nonceliac Gluten Sensitivity
Biesiekierski J, et al. Nutr Clin Pract 2014
It is possible NCGS patients may actually have undiagnosed celiac disease
Surveyed 248 people who believed they had NCGS
147 completed survey
Mean age 43 years
88% female
62% were not properly excluded for celiac disease Many that had a biopsy were on a gluten-free diet 15% had no serological/HLA tests or intestinal biopsy
56Shelley Case, RD
Characteristics of Patients Who Avoid Wheat and/or Gluten in the Absence of Celiac Disease
Tavakkoli A, et al. Dig Dis Sci 2014
Patients who avoid wheat and/or gluten (PWAWG) are a heterogeneous group; predominately self-diagnosed before presenting to physician office
Cross-sectional study at Celiac Center at Columbia University in NYC
Retrospective analysis compared three patient groups: 84 PWAWG 585 Celiac disease 2686 NHANES
Baseline characteristics, lab values, medical co-morbidities
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Characteristics of Patients Who Avoid Wheat and/or Gluten in the Absence of Celiac Disease
Tavakkoli A, et al. Dig Dis Sci 2014
PWAWG…
57/84 (68%) received endoscopy 28/57 (49%) on GF diet at time of endoscopy Median time on GF diet at time of endoscopy was 1
year
32 alternative diagnoses made in 25 (30%) SIBO (16) Fructose intolerance (5) Lactose intolerance (3) Other Food intolerances (3) Microscopic colitis (3) Gastroparesis (1) Pelvic floor dysfunction (1)
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Intestinal Cell Damage and Systemic Immune Activation in Individuals Reporting Sensitivity to
Wheat in the Absence of Celiac Disease
Uhde M, et al. Gut 2016 Three groups of patients:
Reported symptoms from wheat (celiac disease and wheat allergy ruled out)
Celiac disease
Healthy controls
Analyzed sera for markers of intestinal damage and systemic immune response to microbial components
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Intestinal Cell Damage and Systemic Immune Activation in Individuals Reporting Sensitivity to
Wheat in the Absence of Celiac Disease
Uhde M, et al. Gut 2016
Pts with sensitivity to wheat in absence of CD:
Significantly increased serum levels of soluble CD14 and lipopolysaccharide (LPS)-binding protein; antibody reactivity to bacterial LPS and flagellin;
Significantly elevated fatty acid-binding protein 2 (FABP2)
– marker of intestinal epithelial cell damage Significant change towards normalization of the levels
of FABP2 and immune activation markers in a subgroup of pts with wheat sensitivity on a diet free of wheat and related grains
60Shelley Case, RD
Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 11
Intestinal Cell Damage and Systemic Immune Activation in Individuals Reporting Sensitivity to
Wheat in the Absence of Celiac Disease
Uhde M, et al. Gut 2016
Study did not “address the mechanism or molecular triggers responsible for driving the presumed loss of epithelial barrier integrity and microbial translocation.”
Further studies needed
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Gluten or Other Components in Foods
Controversial whether it is gluten or other components in wheat such as fructans which are part of FODMAP’s that may cause symptoms
FODMAP’s are short-chain, rapidly fermented carbohydrates that can trigger GI symptoms in some patients
F = fermentableO = oligosaccharides (fructans and galacto-oligosaccharides)D = disaccharides (lactose)M = monosaccharides (fructose)A = andP = polyols (sorbitol and mannitol)
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FODMAP’s
* Wheat, rye and barley contain:- fructans (CHO) - gluten (protein)
FODMAP CHOs EXAMPLES
Fructans - Barley*, Rye*, Wheat*- Artichoke, Chicory Root, Dates, Figs, Garlic, Inulin, Leek, Onion, Watermelon
Galactans Black Beans, Chickpeas, Kidney Beans, Lentils, Soybeans
Lactose Ice Cream, Milk, Soft Cheeses
Fructose - Agave, High-Fructose Corn Syrup, Honey, - Fruits (Apple, Cherry, Mango, Peach, Pear, Prune, Watermelon)- Vegetables (Artichoke, Asparagus, Sugarsnap Peas)
Some Fruits/Vegetables and Sugar Alcohols
- Fruits (Apples, Apricot, Blackberry, Nectarine, Peach, Pear, Plum, Prune, Watermelon)- Vegetables (Cauliflower, Button Mushroom, Snow Peas, Sweet Corn)- Maltitol, Mannitol, Sorbitol, Xylitol
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Non-Celiac Gluten Sensitivity (NCGS)
Key Points Need to rule out CD and wheat allergy
NCGS: Heterogeneous group with several subgroups GI and non-GI symptoms Prevalence rates highly variable Pathophysiology is poorly understood No biomarkers for diagnosis Need rigorous prospective randomized DBPC studies
Use purified gluten vs wheat-based foods (gluten, non-gluten proteins, fructans)
Treatment of NCGS? Gluten-free diet Temporary low FODMAP Diet Other?
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Questions “GLUTEN”
General name for specific proteins (prolaminsand glutelins) in the grains wheat, rye, barley
Challenge because gluten-containing grains found in a wide variety of foods and beverages
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Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know
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Avoid Barley Bulgur Couscous Durum Einkorn* Emmer* Farro* Kamut* Malt** Malt Extract** Malt Flavoring**
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Malt Vinegar** Regular Oats *** Rye Semolina Spelt (Dinkel)* Triticale Wheat Wheat Bran Wheat Flour Wheat Germ Wheat Starch****
* Types of wheat** Derived from barley*** Often contaminated with wheat/barley/rye**** Unless specially processed Shelley Case, RD
Frequently Overlooked Items That May Contain Gluten
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Corn and rice cereals
Sauces, soy sauce, salad dressings, marinades
Seasonings, specialty prepared mustards
Breading, stuffing, gravy
Soups, soup bases, broth, bouillon cubes
Meat loaf, sausages, hot dogs, other processed meats, burgers (beef, fish, chicken)
Meat substitutes (vegetarian burgers, textured vegetable protein)
Self-basting poultry, imitation seafood
Shelley Case, RD
Frequently Overlooked Items That May Contain Gluten
Baked beans, dry roasted or flavored nuts
Seasoned rice mixes and rice pilafs
Seasoned potato chips, corn chips and other snack foods
Chocolate bars, chocolates, licorice
Flavored and herbal teas, flavored coffees, coffee substitutes
Beer, ale and lager
Communion wafers
69Shelley Case, RD
Frequently Questioned Ingredients
Vinegars
Barley Grass & Wheat Grass
Autolyzed Yeast / Yeast Extract
Barley Malt
Caramel
70Shelley Case, RD
Frequently Questioned Ingredients
Spices, Herbs & Seasonings
Wheat Starch
Modified Food Starch
Dextrin
Maltodextrin
Glucose Syrup
71Shelley Case, RD
Alcohol
Distilled Alcohols
Liqueurs
Wine
Beers
Gluten-Containing
Gluten-Reduced
Gluten-Free
72Shelley Case, RD
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Naturally Gluten-Free Foods
Plain meat, fish, poultry, eggs, nuts, seeds, pulses
Milk, most yogurt and cheese products
Fruits and vegetables
Butter, margarine, oils
Sugars, honey, molasses
Cereals, pasta, breads and other baked products made from gluten-free alternatives
Gluten-free grains (pure, uncontaminated)
73Shelley Case, RD
GF Grains, Seeds, Flours & Starches
Arrowroot Amaranth Buckwheat Corn Flax Mesquite flour Millet Nut flours (almond,
hazelnut, pecan) Oats (pure,
uncontaminated) Potato Starch, Potato Flour
74
Pulses/Pulse flours (beans, chickpeas, lentils, peas)
Quinoa Rice (black, brown, purple,
red, white, wild) Rice Bran Sorghum Soy Tapioca Teff
Shelley Case, RD
Safety ofNaturally Gluten-Free
Grains, Flours, Starches and Seeds
75Shelley Case, RD
Gluten Contamination in Oats
76Shelley Case, RD
Courtesy of Farm & Food Care Saskatchewan
Gluten Contamination in the Canadian
Commercial Oat SupplyKoerner TB, et al. Food Additives and Contaminants 2011
93% samples were over 20 ppm (21-3784)
77
Type of Oat Range (ppm)
Median(ppm)
Mean(ppm)
Steel-cut oats 55-1467 660 645Rolled/flaked/oatmeal 0-2485 81 316Quick/minute oats 13-3784 534 655Oat bran 37-3469 280 704
Shelley Case, RD
Gluten Equivalents
78
20 ppm = 20 mg/kg = 2 mg/100 g
100 ppm = 100 mg/kg = 10 mg/100g
Shelley Case, RD
ppm mg/kg mg/100 g20 20 2100 100 10
SG1
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Gluten Detection in Foods Available in the United States: A Market
SurveySharma G, et al. Food Chemistry 2015
FDA investigated extent of gluten cross-contamination GF labeled foods (275) Non-GF labeled foods without wheat/rye/barley in
the ingredient list (186)
Analyzed products Ridascreen R-7001 Gliadin ELISA Morinaga wheat protein sandwich ELISA
Samples from local grocery stores
79Shelley Case, RD
Gluten Detection in Foods Available in the United States: A Market Survey
Sharma G, et al. Food Chemistry 2015
Gluten-Free Label Claim No Gluten-Free Label Claim
Total Samples 275 186
Gluten Range ppm 5.8-554 5.3-1566
Products > 20 ppm 3/275 (1%) 36/186 (19.4%)
Products > 100ppm 1 out of the 3 above 19 out of the 36 above
Wheat/Gluten Advisory Statement on
Label
> 20ppm
29/275 (10.5%)
1/29 (3.5%)
53/186 (28.5%)
18/53 (34%)
12 cereals3 grains/seeds/legumes/nuts
2 granola/bars1 snack food
Products with Oats
> 20 ppm
11/275 (4%)
1/11 (9%)
44/186 (23.7%)
29/44 (66%)
80Shelley Case, RD
Gluten Contamination of Naturally Gluten-Free Flours & Starches Used by Canadians with Celiac
Disease
Koerner T, et al. Food Additives and Contaminants 2013
Health Canada investigated extent of gluten cross-contamination in naturally gluten-free flours & starches (no oat products)
Analyzed 640 samples for gluten
Samples from 8 Canadian cities between 2010-2012
Grocery stores, health food stores and internet stores
Products from Canada, USA, Europe & other countries
640 samples ranged from 5-7995 ppm
9.7% (62/640) samples > 20 ppm
81Shelley Case, RD
Claims on Package# Samples> 20 ppm
Percentage (%)
Gluten-Free 3/268 1.1
No Gluten-Free Statement 30/298 10
Gluten Precautionary Statements
29/74 39.2
TOTAL 62/640 9.7%
Koerner T, et al. Food Additives and Contaminants 2013
82Shelley Case, RD
Gluten Contamination of Naturally Gluten-Free Flours & Starches Used by Canadians with
Celiac Disease
Recommendations for Purchasing Gluten-Free Specialty Products
83Shelley Case, RD
Choose gluten-free flours, starches, mixes, baked products, cereals and pastas from companies:
Labeled “gluten-free” Good manufacturing practices with rigid quality control Protocols test ingredients and final products for gluten using
appropriate methods
Avoid buying from bulk bins or stores that buy products in bulk and re-package into smaller containers because the area and equipment can easily be cross-contaminated with gluten-containing items.
SG2
Cross Contamination
Store all GF products in separate labeled containers
Separate location in the cupboard for GF foods
Store GF flours and grains in the cupboards above gluten containing foods. Flour dust and bread, cookie and cracker crumbs can easily end up on GF containers and boxes if you are not careful
Separate butter/margarine, jam, peanut butter containers
Use squeeze bottles of condiments and salad dressings
Buy bright stickers and put on gluten-free items especially flours, starches, jam, peanut butter, etc.
84Shelley Case, RD
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Cross Contamination
Wash counter tops, cutting boards and microwave frequently
Thoroughly wash pots, utensils and baking pans
Separate utensils and GF baking items (e.g., sifter, wooden spoons, muffin tins, cookie sheet)
Separate pasta colander
Separate bread machine
85Shelley Case, RD
Cross Contamination
Separate toaster
Toaster oven
Toaster bags
86Shelley Case, RD
Gluten-free
SG3
Food Labeling
87
“Personally, I don’t touch anything without first having a look at the list of ingredients.”
(Guidelines For A Gluten-Free Lifestyle – Celiac Disease Foundation) Shelley Case, RD
USA
Gluten-Free Labeling
88Shelley Case, RD
“Gluten-Free Labeling of Food”CFR Part 101, Section 101.91 (21 CFR 101.91)
FDA final rule August 5, 2013 Voluntary use of a gluten-free claim
Applies to:- Packaged foods- Dietary supplements- Infant formulas- Medical foods- FDA regulated alcoholic beverages
Does not apply to:- USDA regulated products- TTB regulated alcoholic beverages- Cosmetics, prescription and non-prescription drugs
89Shelley Case, RD
Allowed terminology:- Gluten-free- No gluten- Free of gluten- Without gluten
Product must be less than 20 ppm gluten Prohibited grains
- Wheat- Barley- Rye
Oats sold as a single ingredient must be < 20 ppm When oats used in a multi-ingredient food, final product
must be < 20 ppm. Oats do not have to be specially produced to be used as ingredients in foods labeled “gluten free”.
90Shelley Case, RD
“Gluten-Free Labeling of Food”CFR Part 101, Section 101.91 (21 CFR 101.91)
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“Gluten-containing grain” means any one of the following grains or their crossbred hybrids:
- wheat, rye and barley
91Shelley Case, RD
“Gluten-Free Labeling of Food”CFR Part 101, Section 101.91 (21 CFR 101.91)
92Shelley Case, RD
“Gluten-Free Labeling of Food”CFR Part 101, Section 101.91 (21 CFR 101.91)
“Gluten-free” means the food is:
* Inherently gluten free OR
* Does not contain an ingredient that is:- An ingredient that is a gluten-containing grain (e.g., spelt wheat)- Derived from a gluten-containing grain that has not been processed
to remove gluten (e.g., wheat flour)- Derived from a gluten-containing grain that has been processed to
remove gluten (e.g., wheat starch), if the use of that ingredient results in the presence of 20 ppm or more gluten in the food
* Any unavoidable presence of gluten in food must beless than 20 ppm
CANADA
All priority allergens and gluten sources must be declared on the label of
pre-packaged foods
“1220 - Enhanced Labelling For Food Allergensand Gluten Sources and Added Sulphites”
93Shelley Case, RD
Priority Allergens Wheat or triticale Peanuts Almonds, Brazil Nuts, Cashews,
Hazelnuts, Macadamia Nuts, Pecans, Pine Nuts, Pistachios or walnuts
Milk Eggs Soybeans
Crustaceans Shellfish Fish Sulphites (> 10 ppm) Sesame Seeds Mustard Seeds OR any protein, modified
protein or protein fraction from any of the above foods
Barley Rye Wheat Triticale Oats* OR any gluten protein, modified gluten protein or gluten protein
fraction from any of the above cereals
Definition of Gluten
94Shelley Case, RD
Gluten-Free Regulation
Revised February 16, 2011 with Schedule 1220
“Gluten-Free” B.24.018
“It is prohibited to label, package, sell or advertise a food in a manner likely to create an impression that it is a gluten-free food if the food contains any gluten protein or modified gluten protein, including any gluten protein fraction, referred to in the definition of “gluten” in subsection B.01.010.1 (1).”
95Shelley Case, RD
B.01.010.1 (1)
“gluten” means
(a) any gluten protein from the grain of any of the following cereals or from the grain of a hybridized strain that is created from at least one of the following cereals:
(i) barley,(ii) oats,(iii) rye,(iv) triticale,(v) wheat; or
(b) any modified gluten protein, including any gluten protein fraction, that is derived from the grain of any of the cereals referred to in paragraph (a) or from the grain of a hybridized strain referred to in that paragraph. (gluten)
96Shelley Case, RD
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Health Canada’s Position on Gluten-Free Claims
Only the term “gluten free” is allowed
Gluten-free foods must not exceed 20 ppm gluten threshold
97Shelley Case, RD
2015
98
Marketing AuthorizationExemption from Food & Drug
Regulations The food contains no oats other than specially
produced “gluten-free oats”
Do not specify the method or controls to should use to produce gluten-free oats
Finished product does not contain greater than 20 ppm of gluten from wheat, rye, barley, or their hybridized strains
The “gluten-free oats” are clearly identified as such in all cases where ‘oats’ are referenced, including the list of ingredients
99Shelley Case, RD
Gluten-Free Oat Production
100
Purity Protocol
Cleaned Commodity Oats
Dedicated Fields(no wheat, rye or barley)
Yes No
Pure Oat Seed Yes No
Field Inspections Yes No
Dedicated or Thoroughly Cleaned Equipment
Yes No
Dedicated Mill for Processing
Yes Variable
Frequent Gluten Testing Yes Variable
Shelley Case, RD
Definition of the “Purity Protocol” for Producing Gluten-Free Oats
Accepted for publicationhttp://dx.doi.org/10.1094/CCHEM-01-17-0017-VO
www.gluten.org
“Consensus definition of the Purity Protocol requirements based on input from the four largest Purity Protocol oat processors in North America. This definition provides transparency to gluten-free consumers and allows for auditing of Purity Protocol claim.”
Dr. Laura K Allred, Gluten Intolerance Group of North America, GFCOMs. Cynthia Kupper, Gluten Intolerance Group of North America, Mr. Gary Iverson, Montana Gluten Free, Mr. Tracy B. Perry, Cream Hill Estates, Ltd.Mr. Seaton Smith, GF Harvest / Canyon OatsMr. Robert Stephen, Avena Foods Limited
Shelley Case, RD101
1-3 wheat or barley kernels/kg of oats....
> 20ppm
1 kg oats = 20,000 – 25,000 kernels
Contamination of Gluten-Free Oats
102Shelley Case, RD
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Guidelines for Incorporating Oats in the Gluten-Free Diet
103Shelley Case, RD
Celiac disease should be well controlled Celiac antibody levels normalized Symptoms resolved
Use pure, uncontaminated gluten-free oats Start with small amounts Gradually increase as tolerated
Oats are high in fiber Changes in stool pattern and/or possible GI symptoms
Reaction to oats Few case reports of intolerance to pure, uncontaminated oats Eliminate oats and consider re-challenge If reaction during re-challenge contact MD Consultation with dietitian to evaluate and ensure no hidden
gluten104
Overview of Guidelines for Introducing Oats
Shelley Case, RD
Safety IssuesGluten Threshold Levels
105Shelley Case, RD
Gluten Threshold in GF FoodsIT TAKES TWO TO TANGO!
The daily gluten intake is the product of gluten ppm in food and daily intake of wheat substitutes
Then the decision on the gluten threshold in GF food must take into account the variable intake of wheat substitutes
106From Dr. Alessio Fasano
Intake of Gluten and ppm of Gluten in Food
50 g 100 g 200 g 300 g
200 ppm 10 mg 20 mg 40 mg 60 mg
100 ppm 5 mg 10 mg 20 mg 30 mg
50 ppm 2.5 mg 5 mg 10 mg 15 mg
20 ppm 1 mg 2 mg 4 mg 6 mg
107Catassi et al. Am J Clin Nutr. 2007;85:160-6 Shelley Case, RD
Multicenter, DBPC randomized trial 49 adults with biopsy-proven celiac disease; 39 completed
study On strict GFD for > 2yrs Given capsule with 0, 10 or 50 mg gluten/d for 3 months Clinical symptoms, blood and biopsy tests before and after
study Large individual variability in the sensitivity to traces of
gluten 50 mg/d produced significant damage in the small
intestinal mucosa One patient developed symptoms at 10 mg/d Conclusion: “The ingestion of contaminating gluten should
be kept lower than 50 mg/d in the treatment of CD.”108Shelley Case, RD
Gluten Threshold StudyCatassi et al. Am J Clin Nutr. 2007;85:160-6
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Intake of Gluten and ppm of Gluten in Food
50 g 100 g 200 g 300 g
200 ppm 10 mg 20 mg 40 mg 60 mg
100 ppm 5 mg 10 mg 20 mg 30 mg
50 ppm 2.5 mg 5 mg 10 mg 15 mg
20 ppm 1 mg 2 mg 4 mg 6 mg
Catassi et al. Am J Clin Nutr. 2007;85:160-6 109Shelley Case, RD
The Dose-Effect Response (typical CD cases)
From Dr. Alessio Fasano 110
Nutritional Quality of Gluten-Free Foods
and Specialty Products
111Shelley Case, RD
Gluten-Free Product Formulations
White rice flour, corn starch, potato starch and tapioca starch are the staples for baking and in most GF specialty products
Many gluten-free products:
higher in carbohydrate, sugar, fat & calories
lower in fiber, B vitamins, iron, protein
not enriched with iron and B vitamins like their gluten-containing counterparts
112Shelley Case, RD
Oat Nutrition
Source of dietary fiber, both soluble (β-glucans) and insoluble fibers
B-complex vitamins: thiamin, niacin and riboflavin
Iron
Protein
113Shelley Case, RD
Oat Power
114
Oat Flour Oat Bran White Rice Flour
Tapioca Starch
Cornstarch Potato Starch
Protein (g) 18 16 9 0 0.3 0.2Fiber (g) 11 15 4 0 1 0
Carbohydrate (g) 79 62 127 106 117 158
Iron (mg) 7.7 5.1 0.6 0 0.6 2.9
Calcium (mg) 66 55 16 28 3 19Zinc (mg) 2.6 2.9 1.3 N/A 0.1 N/A
Magnesium (mg) 83 221 55 N/A 4 N/A
Thiamin (mg) 0.8 1.1 0.22 N/A 0 0
Riboflavin (mg) 0.13 0.21 0.03 N/A 0 0
Folate (mcg) 65 49 6 N/A 0 N/A
* Chart excerpted from Gluten Free: The Definitive Resource Guide by Shelley Case, RD** Nutrient Information based on one cup of flour Shelley Case, RD
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Gluten-Containing vs. Gluten-Free Flour Comparison
Enriched White Flour
Whole Wheat Flour
White Rice Flour
Tapioca Starch
Cornstarch Potato Starch
Protein (g) 13 16 9 0 0.3 0.2
Fiber (g) 3 13 4 0 1 0
Carbohydrate (g) 95 86 127 106 117 158
Iron (mg) 5.8 4.3 0.6 0 0.6 2.9
Calcium (mg) 19 41 16 28 3 19
Zinc (mg) 0.9 3.1 1.3 N/A 0.1 N/A
Magnesium (mg) 28 164 55 N/A 4 N/A
Thiamin (mg) 0.98 0.6 0.22 N/A 0 0
Riboflavin (mg) 0.62 0.2 0.03 N/A 0 0
Folate (mcg) 364 53 6 N/A 0 N/A
* Chart excerpted from Gluten Free: The Definitive Resource Guide by Shelley Case, RD** Nutrient Information based on one cup of flour 115Shelley Case, RD
GF Grains, Seeds, Flours & Starches
Greater variety of grains, seeds and flours in gluten-free products:
Better flavor and texture
Improved nutritional profile
116Shelley Case, RD
Pulse Power
Pulses and Pulse Flours (Legumes)
Nutrient dense
fiber, protein, B vitamins, iron, other minerals and vitamins
Low glycemic index
Low in fat
Economical
117Shelley Case, RD
SG4
Pulse PowerChickpea (Garbanzo
Bean) Flour
Yellow Pea Flour
White Rice Flour
Tapioca Starch
Cornstarch Potato Starch
Protein (g) 26 41 9 0 0.3 0.2
Fiber (g) 18 21 4 0 1 0
Carbohydrate (g) 67 105 127 106 117 158
Iron (mg) 6.3 8.0 0.6 0 0.6 2.9
Calcium (mg) 85 134 16 28 3 19
Zinc (mg) 3.2 5.4 1.3 N/A 0.1 N/A
Magnesium (mg) 157 214 55 N/A 4 N/A
Thiamin (mg) 0.64 1.08 0.22 N/A 0 0
Riboflavin (mg) 0.14 0.22 0.03 N/A 0 0
Folate (mcg) 309 23 6 N/A 0 N/A
* Chart excerpted from Gluten Free: The Definitive Resource Guide by Shelley Case, RD** Pulse flours analyzed by Silliker Canada June 2010*** Nutrient Information based on one cup of flour 118Shelley Case, RD
www.pulsecanada.com
119Shelley Case, RD
Almond Flour PowerBlanched
Almond FlourNatural
Almond FlourWhite Rice
FlourTapioca Starch
Cornstarch Potato Starch
Protein (g) 24 21 9.4 0 0.3 0.2
Fiber (g) 11 13 3.8 0 1.2 0
Carbohydrate (g) 21 22 127 119 117 158
Iron (mg) 3.7 3.7 0.6 0 0.6 2.9
Calcium (mg) 264 269 16 0 3 19
Zinc (mg) 3.3 3.1 1.3 0 0.1 N/A
Magnesium (mg) 300 270 55 0 4 N/A
Riboflavin (mg) 0.8 1.14 0.03 0 0 0
Niacin (mg) 3.9 3.6 4.1 0 0 0
* Chart excerpted from Gluten Free: The Definitive Resource Guide by Shelley Case, RD** Nutrient Information based on one cup of flour 120Shelley Case, RD
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Healthy Gluten-Free Diet Tips
Choose naturally gluten-free, nutritious foods
Lean meat, poultry, fish, eggs, nuts, seeds, fruits, vegetables, pulses (legumes), low fat dairy products, whole grains
Increase intake gluten-free whole grains
Amaranth, buckwheat, millet, oats, quinoa, sorghum, teff, rice (black, brown, red, wild)
121Shelley Case, RD
Healthy Gluten-Free Diet Tips
Fiber-rich foods
Iron-rich foods
Calcium-rich foods/beverages
Vitamin D-rich foods/beverages
122Shelley Case, RD
Healthy Gluten-Free Diet Tips
Compare gluten-free specialty products
Review ingredients and nutrition facts table
Limit products high in sugar, fat and calories
Choose products:
healthy whole grains
enriched/fortified
more protein, fiber, vitamins/minerals
123Shelley Case, RD
Alternative Therapies
124Shelley Case, RD
Why Alternatives to GFD Needed?
GFD is challenging and expensive
Gluten contamination – eating out, food manufacturing, etc.
Up to 60% of adult pts are symptomatic despite GFD
Incomplete healing of intestinal mucosa in many pts
Evidence of persistent mucosal inflammation
Mucosal recovery post-diagnosis Adults: 34% at 2 years; 66% at 5 years; 90% at 9
years Children: 95% by 2 years; 100% long-term
Persistent symptoms
125Slide adapted from Verdue, EF. McMaster University Shelley Case, RD
Alternative Therapies in Celiac Disease
New strategies for treating celiac disease are currently being researched
Celiac Safe Wheat
Gluten Sequestering Polymers
Antigen Presentation Suppressors
Modulation of Inflammatory Response
Vaccines
Enzyme Therapies
126Shelley Case, RD
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Commercial Enzyme Supplements
Different from purified supplements used in clinical trials
OTC enzyme supplements destroyed by acid and pepsin in the stomach
Cannot break down gliadin peptides in the stomach before they reach the small intestine
Research has shown these commercial supplements are not effective and should not be used by those with CD or NCGS
127Shelley Case, RD
Resources
128Shelley Case, RD
Gluten Freedom
129Shelley Case, RD 130Shelley Case, RD
* CD, DH, NCGS* Foods & ingredients allowed and to avoid* Frequently questioned ingredients* Oats* Alcohol* Gluten threshold levels, ppm & testing* GF food labeling in the US & Canada* Nutrition* GF meal planning* GF shopping/shopping list* Cross-contamination at home & away from home* GF cooking & baking* Recipes* GF product listing by company & product name* GF company directory* GF resources* Appendices* Extensive reference list
www.shelleycase.com
SG5
Pocket Dictionary:Acceptability of Foods & Food
Ingredients for the Gluten-Free Diet
* 300+ food and food ingredients
* Description of each item
* Allowed, Not Allowed or ? Check
* 300+ food additives
* Large font for easy reading
* Pocket size, easy-to-carry
www.celiac.ca
131Shelley Case, RD
Other Resources
Organizations- Celiac Disease Foundation www.celiac.org- Gluten Intolerance Group www.gluten.org- Beyond Celiac www.beyondceliac.org- Canadian Celiac Association www.celiac.ca
Tricia Thompson, RD www.glutenfreewatchdog.org
Dr. Steve Plogsted, PharmD, Nationwide Children’s Hospital, Columbus, OH www.glutenfreedrugs.com
132Shelley Case, RD
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