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Gluten-Free Round-Up: Non- responsive celiac disease, oats, probiotics & arsenic Melinda Dennis, MS, RDN National Celiac Association Fall Meeting October 29, 2017

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Page 1: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Gluten-FreeRound-Up:Non- responsiveceliacdisease,oats,probiotics

&arsenic

MelindaDennis,MS,RDNNationalCeliacAssociationFallMeetingOctober29,2017

Page 2: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Disclosures• NutritionCoordinator,CeliacCenter,BethIsraelDeaconessMedicalCenter

• Founder/Owner:DeletetheWheat,LLCNutritionalConsulting

• SeniorNutritionConsultant,NationalCeliacAssociation• Co-investigator,arsenicstudy[pending]• Co-author,articleonprobiotics[JournalofAcademyofNutritionandDietetics,2017]

Page 3: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Non- ResponsiveCeliacDisease(NRCD)• NRCDistheblankettermfor

• persistentorrecurrentsymptoms• persistentsigns,orlaboratoryabnormalitiestypicalofceliacdisease(CD)despite6-12monthsofdietaryglutenavoidance

• NRCDiscommon,affectingfrom7-30%ofpatientstreatedwithagluten-freediet(GFD)forCD.

Page 4: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,
Page 5: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Others included: Peptic ulcer disease (2), Crohn’s disease (1), Duodenal adenoCA (1), Food allergy (1), Gastroparesis (1)

Non-Responsive” Celiac DiseasePersistent or recurrent signs/symptoms occur in

~30% of patients

Leffleretal,CGH2007;VeeraraghavanACG2015

Page 6: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

InanFDA-regulatedFoodProductNotLabeledGluten-FreeAvoidtheFollowing:• WheatRye Barley• MaltOats Brewer’syeast• Yeastextract Autolyzedyeastextract

• IfanUSDA-regulatedfoodisnotlabeledgluten-free,alsoavoidmodifiedfoodstarch,dextrinandstarch.

• IfyoudonotseeanyofthesewordsonthelabelofanFDA- orUSDA-regulatedfood,theproductisunlikelytoincludeanygluten-containingingredients.

• Cross- contaminationisstillpossible(variesbyproduct).

ThompsonT.ADAPocketGuidetoGluten-FreeStrategiesforClientswithMultipleDietRestriction,2nded.Chicago,IL:AcademyofNutritionandDietetics;2016

Page 7: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Naturally gluten-free grains, flours, and products made from them

may be contaminated with wheat, barley, and/or rye.

Choose labeled gluten-free versions of these products.

Celiac Disease Celiac Disease Toolkit. American Dietetic Association. Chicago, IL, 2011; Thompson T, Lee AR, Grace T. J Am Diet Assoc. 2010;110:937-940.

Page 8: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Top13FrequentlyOverlookedSourcesofGluten: Doyou…..?

• Periodicallycheckmedicationsandsupplements

• Buygrainslabeledgluten-free• Understandfoodlabelinglaws• Check/rechecklabels• Checkgum,mints,candy• Modifyreligiouspractices• Educatefamily,friends,roommate,guests,schools,co-workers,camps,nursinghomes

• Strategizediningoutsidethehome

• Intentionallyeatgluten• Knowinglyeatfoodsthatmaybecontaminatedwithgluten

• Eatoats• Drinkglutenreducedorremovedbeer

• Thinkaboutsushi,pizza,tortillas,bakeries,hotchocolatemix…

• Others????

Thislistisnotcomprehensive.

Page 9: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

FrequentlyOverlookedSourcesofGlutenorPotentialSourcesofGluten• Autolyzedyeastextract/Yeastextract

• Beer/Ale/Lager• Breading/batter• Brewer’syeast• Broth/BouillonCandy• Communionwafers• Croutons• Dressing

• Drinkmixes• Flour/grain/cerealproducts (notlabeledgluten-free)

• Frenchfries• Gravy• Herbaltea• Imitationbacon• Imitationseafood• Malt/maltextract• Marinades

Thislistisnotcomprehensive.

Page 10: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

FrequentlyOverlookedSourcesofGlutenorPotentialSourcesofGluten• Matzoandmatzomeal• Medications/Supplements

• Oats(unlesslabeledglutenfree)

• Panko• Pasta• Play-Doh™• Preparedmeat,fish,poultry,meatalternatives

• Processedluncheon/delimeats

• Ricemixes• Saladdressing• Sauces• Seasonings• Soupbases• Soysauce• Stuffing• Thickeners(Roux)• Vegetablesinsauce• Winecoolers

Thislistisnotcomprehensive.

Page 11: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

OatsandCeliacDiseaseOneofthemostimportantwholegrainfoods,highinfiber,Bvitamins,ironandprotein(2xthatofrice)

Manycontrolled,shortandlong-termstudiesofadultsandchildrenindicateoatsaresafeforconsumptionbythemajorityofpatientswithCDandDH1.

SubsetofCDpatientsexistswithanexaggeratedimmuneresponsetooats2.mmnCrosscontaminationwithglutencontaininggrainsisalargeconcern.

InclusionofoatsintheGFDremains adecades-longcontroversialtopicacrosstheglobe.3 Officialrecommendationsvaryamonggroups.

1. Janatuinen et al, Gut 2002; Peraaho et al, Scand J Gastroenterol 2004; Storsrud et al, Br J Nutr 2003; Storsrud et al, Eur J Clin Nutr 2003; Reunala et al, Gut 1998; Hoffenberg et al, J Pediatr 2000; Hoberg et al, Gut 2004: Kupper C, Gastroenterol 2005; Hardy et al J Autoimmunity 2014; 2. Lundin et al, Gut 2003; Peracho et al, Scand J Gastroenterol, 2004; Arentz-Hansen H. PLoS Med. 2004; 3. Fric et al, Nutr Clin Care, 2011

OATS

Page 12: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Swedishchildrenwithceliacdiseasecomplywellwithagluten-freediet,andmostincludeoatswithoutreportinganyadverseeffects:along-termfollow-upstudy

• Oatswereincludedinthedietof89.4%ofthechildrenforameanof3.4years.

• Most(81.9%)atepurifiedoats,and45.3%consumedoatslessthanonceaweek.

• Amongthosewhodidnotconsumeoats,only5.9%refrainedbecauseofsymptoms.

• GeneralcompliancewiththeGFDwasgood.

• Mostpatientsdidnotreportadverseeffectsafter long-termconsumptionofoats.

TapsasD,etal.NutrRes.2014May;34(5):436-41.

Page 13: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Oats- DidyouKnow?• Untilrecently,purityprotocolGFoatshavebeentheonlyoatslabeledgluten-freeandrecommendedfortheGFcommunity.

• CertainGFgrainmillershavebeenmechanicallysortingoatsandsellingthemtomanufacturers(bothlargeandsmallcompanies)ofGFoatsandoatbasedproductssince2012.

• SomeGFcompaniesareusingacombinationofboth.• Itisnearlyimpossibletodistinguishpurityprotocoloatsfrommechanicallysortedoats

GlutenFreeWatchdog.https://www.glutenfreewatchdog.org/news/the-gluten-free-oats-situation-why-it-is-such-a-sticky-wicket/.Accessed10/9/17.

seed field facility

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Kernel-basedglutencontaminationofgluten-freeoatmealcomplicatesglutenassessmentasitcausesbinary-liketestoutcomes

InternationalJournalofFoodScience&TechnologyVolume52,Issue2,pages359-365,20OCT2016http://onlinelibrary.wiley.com/doi/10.1111/ijfs.13288/full#ijfs13288-fig-0001

1outof57servingswerenotincompliancewiththeFDAGFlabelingrule.

Page 15: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

GlutenFreeWatchdog’s(GFWD)StanceonOats

• RemainssupportiveoftheuseofpurityprotocoloatsforpersonswithCDandgluten-relateddisorderswhotolerateoats.However,inlightofthestudyfindingsfromQuakerweaskallsuppliersofpurityprotocoloatstore-evaluatetheirtestingprocedures,includingsamplingmethodologyandtheamountoftestingdoneonoatgroatsandfinishedproduct.

• Supportiveoftheuseofgluten-freeQuakerOatsbypersonswithCDandgluten-relateddisorders.Atthistime,weareNOTsupportiveoftheuseofanyotherproductcontainingsortedoats,includinggluten-freeCheerios,gluten-freeLuckyCharms,andgluten-freeandcertifiedgluten-freeproductssourcingoatsfromGrainMillersorLaCrosseMilling.

• WhenoatsarepulledfromthemarketplacefortestingtheyshouldbetestedusingtheRidascreenGliadinR5ELISAMendezMethodusingthenewprotocolrecommendedbyR-Biopharm

https://www.glutenfreewatchdog.org/news/gluten-free-watchdog-updated-position-statement-on-oats/.AccessedOct2017

Page 16: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

GFWD’sPurityProtocolList• A listofcompaniesfollowingthepurityprotocolandcommentsfromseveralcompaniesusingmechanicallysortedoats

https://www.glutenfreewatchdog.org/news/oats-produced-under-a-gluten-free-purity-protocol-listing-of-suppliers-and-manufacturers/

Page 17: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

WhatGFWDRecommends• Thesituationwithoatscontinuestoevolve.GlutenFreeWatchdog’spositionstatementonoatswillbeupdatedinthenearfuture.Inthemeantime,ouradviceis:

• Chooseyouroatproductsbasedonyourcomfortlevelwithregardtothelevelofinformationprovidedtoyoubymanufacturers.Considerthefollowing:• Doesthemanufacturerdisclosewhethertheyusepurityprotocolorsortedoats?

• Dotheydisclosetheirtestingprotocols?• Dotheydisclosetheassay[test]theyusetotestoatsforglutencontamination?

• Ifamanufacturerrefusestoansweranyofthesequestionsorrespondsbysayingtheinformationisproprietary,moveontoanothercompany.

GlutenFreeWatchdog.https://www.glutenfreewatchdog.org/news/quaker-researchers-publish-a-second-study-highlighting-the-difficulties-associated-with-testing-oats-for-gluten-contamination/.Accessed10/9/17.

Page 18: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

NationalOrganizations:GFOatsStances

• AcademyofNutritionandDietetics,2009• GraduallyincludeGFoatsuncontaminatedwithwheat,barleyorryeatintakelevelsof ~50gdryoats/day;generallysafeandimprovescompliancetotheGFD.

• NorthAmericanSocietyfortheStudyofCeliacDisease,2016• Encouragesconsistent,stringent,transparentandreliabletestingmethodstoensureendproduct<20ppm

• DiscussGFoatswithdoctoranddietitian;monitorIgA-tTGbeforeandafterintroduction.Persistentorrecurrentsymptomsshouldpromptanassessment,mayincludeanintestinalbiopsy.

ExecSummaryofRecommendations- CeliacDisease.InclusionofGlutenFreeOats.ANDEvidenceAnalysisLibrary,2009.https://www.andeal.org/topic.cfm?menu=5279&cat=3726;NASSCDSummaryStatementonOats.http://www.nasscd.org/files/Oats-Statement-NASSCD-April-2016(1).pdf.AccessedOct2017.

Page 19: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Canada’sStance onOats• HealthCanada'sMarketingAuthorization,2015

• Permitstheuseofgluten-freeclaimsforgluten-freeoats(thatdonotcontainmorethan20ppmofglutenfromwheat,rye,barley,ortheirhybridizedstrains)andforfoodscontainingtheseoatsasingredients,undercertainconditions.

• CanadianCeliacAssociationProfessionalAdvisoryCouncilrecommendsguidelinesforaddingpure,uncontaminatedoats:https://www.celiac.ca/oats-statement

• Gluten-freeclaimtoberemovedfromGeneralMillsCheeriossoldinCanadabyJan1,2018(CanadianFoodInspectionAgency)

https://www.canada.ca/en/health-canada/services/food-nutrition/food-safety/food-allergies-intolerances/celiac-disease/gluten-free-labelling-claims-products-containing-specially-produced-gluten-free-oats.html;https://www.celiac.ca/oats-statement;https://www.celiac.ca/gluten-free-claim-removed-general-mills-cheerios-sold-canada.AccessedOct2017

Page 20: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Meta-analysis:SafetyofAddingGFOats• Non-contaminatedoatstoleratedbygreatmajorityofadultsandchildrenwithCDinthestudies

• Datanotrobustenoughfordefinitive,evidence-basedrecommendationsonthesafetyofoatsforpatientswithCD

• Limitedconfidenceduetolowquality,smallsamplesize,limitedgeographicdistributionofdata

• Needmorewell-designedtrialsevaluatingtheeffectofpureoatsintheshort/longterm,inchildren/adultpatientswithCD

• Informationneededre:sourceofoats,includingcultivars,andamount/frequencyofoatsconsumedandcompliancetoGFD

PintoSanchezMI,etal.Gastroenterol,2017

Page 21: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Meta-analysis,cont’d• Purityleveldependsoncountryoforiginandlocalregulations

• Oatproductsneedtobesubjectedtoclinicalstudies.• OatsusedinGFfoodsshouldbeproduced/processedunderprotocolsthatensurepurityduringallphasesofproductionwithreliabletestingmeasuresthatconsistentlyguarantee<20ppmofgluten.

• WeendorsetherecommendationsbyNASSCDtosupporttheuseofpureoatsinCDandmonitorlevelsofIgA-tTGbeforeandaftertheirintroductionintothediet.

• Persistentorrecurrentsymptomsshouldpromptanassessmentthatmayincludeanintestinalbiopsy.

PintoSanchezMI,etal.Gastroenterol,2017

Page 22: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

BIDMCCeliacCenterOatsStance2017

• Morecomfortablewithpurityprotocolprocessatthistime• SomecompaniesmaybedoingagoodjobatconsistentlyprovidingmechanicallysortedGFoats.

• InvestigatehowallGFoatsaregrown,processed,andtestedtoconfirmtheirGFstatus.

• ReadonGlutenfreewatchdog.orgaboutmechanicallysortedversuspurityprotocoloatstofindyourowncomfortlevel.

• Talktoyourceliachealthcareteamtohelpyoumakeaninformeddecision.

Page 23: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

BIDMCCeliacCenterOatsStance,2017• Crosscontaminationisaconcernregardlessofthetypeofoatthatiseaten– purityprotocolormechanicallysorted.

• MoreNorthAmericandataneededonoatsafetyandcontamination

• WecallonALLsuppliersandmanufacturerstoofferconsistentlysafeoatsandoat-basedproductsthatareproventobegluten-freethroughrigorousandprecisetesting,betransparentabouttheirprocess,andprovideevidenceofconsistentfavorableresults<20ppm.

Page 24: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

AddingGFOats:BIDMCCeliacCenter

• DiscussthedecisiontointroduceANYTYPEofGFoatsintoyourdietwithyourdoctor.

• Newlydiagnosedpatients:Avoidoatsuntil CDiswellcontrolled(completeresolutionofsymptomsandnormaltissuetransglutaminaselevel[IgA-tTG]).

• Underphysician/dietitianguidance,thegradualadditionofuncontaminatedlabeledgluten-freeoatsupto50grams/day(alittlemorethan½cupdryrolledoatsor¼cupsteelcutoats)maybeattempted.

• Drinkadequatewater:oatsarehighinfiber.

DennisM,etal.CeliacDiseaseToolkit.Chicago,IL:AcademyofNutritionandDietetics,2011

Page 25: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

AddingGFOats:BIDMCCeliacCenter• Follow-upwithyourgastroenterologistwithin3-6monthsafterintroducingGFoats.

• Symptomsfromeatinggluten-freeoatsmaybedueto1 ormorefactors:• Intolerancetotheincreaseinfiber• Foodintolerances(oatsthemselvesorfructose,otherFODMAPs,etc.asingredientsinoat-basedproducts)

• Glutencontamination• Immuneresponse(rare)tooatproteinsimilartothatofgluten

• Diligentlymaintainroutinefollow-upswithyourmedicalteam.

KupperC.Gastroenterol,2005;Fricetal,NutrClinCare,2005

Page 26: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Whattodoif….• Youhavepersistentsymptomsand/oranelevatedanti-TTGantibodylevelAvoidallGFoats/oatproductsuntilthesesymptomsand/orlevelhavesubstantiallyimproved;followupwithyourdoctor.

• YoudevelopnewsymptomsthatseemtocorrelatewithGFoatingestion?Followupwithanexpertceliacphysiciantodeterminewhetherglutenexposureoranalternativediagnosiscanaccountforthesesymptoms.

• Youwanttoissueacomplaintrelatedtopotentialglutencontamination?ContactMedWatch,theFDA’sAdverseEventReportingSystembyphone:800-332-1088(chooseoption#4tospeaktoaperson)oronline:https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home.Keeptheproduct’sboxorpackagetoreportthebatch/lotnumbertotherepresentative.

NASSCDSummaryStatementonOats.http://www.nasscd.org/files/Oats-Statement-NASSCD-April-2016(1).pdf.AccessedOct2017.

Drawing:AbbyBradley,age11

Page 27: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Bacteria:Youarewhateatswhatyoueat• Microbiome– bacteriaonbodysurfaces• Mostliveinyourcolonoronyourskin• 50%ofstoolweightisbacteria• ~Samenumberofbacteriacellsashumancells• Bacteria:3.3milliongenes:Humans23,000genes1

Adaptedwithpermission:JocelynSilvesterMD,PhD1.Qin,J.Nature464,59-65(2010)

Drawing:AbbyBradley,age11

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Diversityisthespiceofmicrobiallife• 20,000speciesofbacteria(atleast)• Morehealthypeoplehavemore“biodiversity”• Communitypopulationisnotstatic• Somebacteriamorecommoninhealthypeoplethanothers• Thereisno“healthy”microbiome

Bacteria’sRole:• MakeVitaminK• Fermentfibertoproduceshortchainfattyacids• Communicatewithimmuneandnervoussystem

Adaptedwithpermission:JocelynSilvesterMD,PhD

Drawing:AbbyBradley,age11

Page 29: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Probiotics• “Livemicroorganismsthat,whenadministeredinadequateamounts,conferahealthbenefitonthehost”1

• NoevidenceforspecificuseofprobioticsinCD• Enthusiasmexceedsresearch• Difficulttoguideuse,selection,lengthoftime• Clinicaldecision:casebycasebasisforsymptomrelief• Trial,astolerated,andmonitor• Encourageprebioticandprobiotic-richFOODsourcesonaregularbasis,astolerated

1.SandersME.Probiotics:definition,sources,selection,anduses.ClinicalInfectiousDiseases,2008

Page 30: Gluten-Free Round -Up · • Check/recheck labels • Check gum, mints, candy • Modify religious practices • Educate family, friends, roommate, guests, schools, co-workers, camps,

Gluteningrowthmedia?• AnabstractpresentedatDigestiveDiseaseWeekin2014raisedconcernsaboutgrowthmediainprobiotics.

• Thisstudyassessedtheglutencontentofprobiotics:

*FDA-regulatedfoods,includingsupplements,mustcontain<20ppmglutentobelabeledGF.

15werelabeledasglutenfree

2ofthe15productscontained>20ppm*ofgluten(liquidchromatographymassspectrometry)

Nazarethetal.Widespreadcontaminationofprobioticswithglutendetectedbyliquidchromatography-massspectrometry[abstr].ProceedingsofDigestiveDiseaseWeek2014.Presentation108.Gastroenterol.2015;148(4suppl 1):S-714.

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ThomsonT,DennisM,EmersonL.JAcadNutrDiet.2017Sep1.

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Probiotics,DigestiveEnzymes&Gluten• “Bacteria,mold,yeastandenzymesproducedbybacteriaareusedinavarietyofproducts,includingprobioticsanddigestiveenzymes.

• Thesemicroorganismsmaybegrownonmediathatmayincludeingredientsderivedfromwheat,barley,andrye.

• Althoughthebacterialormoldstrainspresentinprobioticsenzymes,supplementscontainingprobioticsorenzymes,andsomefermentedfoodsisdeclared,noinformationonthegrowthmediaistypicallyprovided”.

ThompsonT,etal.JAcadNutrDiet,2017

Probiotic

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Probiotics,DigestiveEnzymes&Gluten• “Bacteria,mold,yeastandenzymesproducedbybacteriaareusedinavarietyofproducts,includingprobioticsanddigestiveenzymes.

• Thesemicroorganismsmaybegrownonmediathatmayincludeingredientsderivedfromwheat,barley,andrye.

• Althoughthebacterialormoldstrainspresentinprobioticsenzymes,supplementscontainingprobioticsorenzymes,andsomefermentedfoodsisdeclared,noinformationonthegrowthmediaistypicallyprovided”.

ThompsonT,etal.JAcadNutrDiet,2017

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ThompsonT,etal.JAcadNutrDiet.2017

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ToSuppliersandManufacturers

• Disclose thecomponentsofgrowthmediatomanufacturers.• Beawareofthepotentialforglutenproteinfragmentstoremaininbacteriagrownongluten-containingmedia

• Deactivate and testwithacompetitiveELISA.• Moreresearchneeded.

Thompsonetal.JANDSept2017

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TotheFDA

• HowAREgrowthmediaforbacteria(andothermicroorganisms)definedinlabeling?

• Ifwheat,barley,orryeareusedasgrowthmedia,cantheybelabeledasglutenfree?

• Iftheuseofglutencontaininggrowthmediaisallowedinagluten-freeproduct,howshouldproductscontainingbacteriaandbacterialenzymesbetestedtoensuresafety?

Thompsonetal.JANDSept2017

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ToConsumers

• Ifyouuseprobiotics,selectproductslabeledglutenfree.• Concerned?Contactmanufacturersandaskquestions,suchas:

• Areanyofthebacteriaorbacterialenzymesusedinyourproductgrownongluten-containinggrowthmedia?

• Ifso,doyoutestbacterialstrainsandfinalproductsforglutencontaminationusingacompetitiveELISA?

• Untilmoreisknownaboutresidualglutenfromgrowthmedia,erringonthesideofcautionandavoidingproductscontainingingredientsgrownongluten-containinggrowthmediamaybebestiftheproductisnottestedforresidualglutenusingacompetitiveELISA.

http://www.sciencedirect.com/science/article/pii/S2212267217310663

Thompsonetal.JANDSept2017

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ArsenicandtheGFD• Anodorless,tastelesselementfoundinsoil,water,andair• OrganicandInorganic(carcinogenic)• Linkedtomanyhealthproblems• Noknownsafeamountofarsenic• HigherlevelsindifferentpartsofU.S.

• Riceisgrownunderfloodedconditionsandwillabsorbarsenicfromboththesoilandthewater.

• Potentiallyhigherriskforpeoplewhoregularlyeatalotofrice,especiallychildren

• Morestudiesneeded

http://www.dartmouth.edu/~arsenicandyou

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TakeActionAgainstArsenic• Howmucharsenicisinyourtapwater?• Howmuchisinyourbottledwater?• Testyoursoil.• Stopsmoking.• Eatricewithlowerlevelsofarsenic.• Soakandrinserawrice(30%reductioninarsenic)• Cook6cupswater:1cuprice.• Discardsomeofthewaterduringcooking.• Besurethewateryouuseforcookingricedoesnotcontainhigharsenic,sincericeabsorbswaterasitcooks.Youshouldnotusewaterwithmorethan10partsperbillionofarsenicforcooking.

http://www.dartmouth.edu/~arsenicandyou/;https://www.glutenfreewatchdog.org/getreport?rid=452;https://www.glutenfreewatchdog.org/news/arsenic-and-rice-update-for-gluten-free-consumers/

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There’smorethan1kindofrice

Sometypesofricehavelessarsenicthanothers.• Quick-cookingrice• Instantrice• SushiricegrownintheU.S.• WhiteBasmatiricefromIndia,Pakistan,orCalifornia(1/2inorganicarsenicofmostothertypesofrice)

• Whitericehas~80%lessinorganicarsenicthanbrownrice.

http://www.dartmouth.edu/~arsenicandyou/

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PassmethealternativeGFgrains!• Reducetheamountofriceandriceproductsyoueat.

• SubstitutericebyROTATINGinothergluten-freepseudo-grains.

• Amaranth,millet,buckwheat,teff,sorghumandquinoaANDdrinkmorewater.

Thesepseudo-grainsarehighinfiberandwillofferyoumanyimportantnutrients:• Vitamins• Minerals• Morenutritiousthanrice

Besuretheyarelabeledgluten-freetoavoidcrosscontaminationwithglutencontaininggrainsduringharvest,transport,andproduction.

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A

B

C

D

E

F

Amaranth

Buckwheat

Millet

Quinoa

Sorghum

Teff

LeslieCerier

LeslieCerier

KristineKiddKristineKiddKristineKidd

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Nutrient Content of Whole GF

Flours Fiber (gm) Folate (mcg) Calcium (mg) Iron (mg)

Amaranth 12.9 158 307 14.69Buckwheat groats 16.9 69 28 4.05

Millet 17.0 170 16 6.02Quinoa 11.9 313 80 7.77Sorghum 12.1 38 54 8.45Teff 15.4 — 347 14.73Wheat flour, whole-grain 14.6 53 41 4.66

Wheat flour, white enriched

3.4 245 422 5.84

ml1 cup, uncooked

NutrientContentofWholeGFGrains:Fiber,Folate,Calcium(1cupuncooked)Iron

USDANationalNutrientDatabase,http://www.nal.usda.gov/fnic/foodcomp/search/index.html

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NutrientContentofGFGrains- BVitamins

Flours Thiamine (B1) (mg)

Riboflavin (B2) (mg)

Niacin (B3) (mg)

B6(mg)

Amaranth 0.22 0.39 1.78 1.14Buckwheat groats 0.37 0.44 8.42 0.579

Millet 0.84 0.58 9.44 0.77Quinoa 0.62 0.54 2.58 0.88Sorghum 0.46 0.27 5.6 1.13Teff 0.75 0.52 6.49 0.93Wheat flour, whole-grain 0.54 0.26 7.6 0.41

Wheat flour, white enriched

0.84 0.52 7.3 0.06

USDA National Nutrient Database, http://www.nal.usda.gov/fnic/foodcomp/search/index.html

1 cup, uncooked

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Thislistisnotcomprehensive.

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Thislistisnotcomprehensive.

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Thankyouto:• TracyPunshon,Ph.D.,Dartmouthresearcher

• JocelynSilvester,MD,PhD

• TriciaThompson,MS,RDNwww.glutenfreewatchdog.org


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