Jolanda M. Denham, MD

Pediatric Gastroenterology, Hepatology and Nutrition

October 21, 2014

NON-CELIAC GLUTEN SENSITIVITY(when it’s not Celiac)

What we will discuss in the next hour (or so)

• Gluten Free is “In”• What is the difference between Wheat Allergy,

Celiac Disease and Non-Celiac Gluten Sensitivity (or Gluten Intolerance)?

• Why being gluten-free when not needed may not be a good idea

Gluten-Free is “IN”

Gluten-free diet becoming an increasingly popular solution. The market grew at a compound annual growth rate of 28% from 2004

to 2008, to finish with almost $4.2 billion in retail sales in 2009. By 2017 the market is expected to reach about $6.4 billionbillion in sales.

Gluten-Free is “in”

–#1 reason for consumers to buy gluten free foods is because a

GFD is thought to be “healthier”“healthier”

–BUT….BUT….

There are questions….

• Is it necessary?• Is it harmful?• Is it cost effective?• Who will benefit?

• What does the science say?

Who benefits from a Gluten-Free Diet?

• Celiac Disease

• Wheat Allergy

• Non-Celiac Gluten Sensitivity

Celiac Disease

It is an autoimmune disease

It is triggered by the consumption of gluten

It affects the small intestine’s digestive process

Occurs in genetically susceptible individuals– Must have DQ2 and/or DQ8 positive HLA haplotype to have celiac disease, but– Just because one has DQ2 and/or DQ8 positive HLA haplotype does not mean they will get celiac disease– Very common in the US– Is necessary but not sufficient

Celiac Disease Celiac disease is an autoimmune disease of the intestines caused by a permanent

sensitivity to gluten in genetically susceptible individuals

OR in other words….

Ingestion of gluten results in the formation of antibodies against tissue transglutaminase (an enzyme found in the intestinal lining)

– Can present with:

Gastrointestinal symptomsNon-gastrointestinal symptoms

Totally asymptomatic

Celiac Disease = Abnormal Lab Tests

Antiendomysial antibodies (EMA)

Anti tissue transglutaminase antibodies (TTG)

HLA typing

Deaminated Antigliadin antibodies (DGA)

Celiac Disease = Abnormal Endoscopy

NodularityScallopingNormal Appearing

Scalloping

Celiac Disease = Abnormal Biopsies

Wheat Allergy

• Immunoglobulin E (IgE) mediated immune reaction to wheat proteins

• Symptoms occur minutes to hours after gluten exposures

• Baker’s Asthma and Rhinitis – based on inhaling wheat flour• Wheezing, cough, runny nose

• Food Allergy – based on eating wheat• Hives, eczema• Anaphylaxis (throat closing, inability to breathe) => DEATH

Wheat Allergy – IgE blood Tests

Component Reference Range Value CORN, ALLERGEN <0.35 kU/L 8.44 (H) EGG WHITE, ALLERGEN <0.35 kU/L >100.00 (H) MILK (COW), ALLERGEN <0.35 kU/L >100.00 (H) OAT, ALLERGEN <0.35 kU/L 57.20 (H) PEANUT, ALLERGEN <0.35 kU/L 87.80 (H) RICE, ALLERGEN <0.35 kU/L 4.74 (H) SESAME, ALLERGEN <0.35 kU/L >100.00 (H) SOYBEAN, ALLERGEN <0.35 kU/L 56.00 (H) WHEAT, ALLERGEN <0.35 kU/L 79.60 (H)

Wheat Allergy – Skin Prick Testing

Wheat Allergy – Treatment

• Avoid all wheat Avoid all wheat – your life may depend on it!

• Always carry the Epi Pen!

But what if all my allergy and celiac testing are negative, I don’t wheeze or have hives when I eat wheat, but I feel awful when I eat gluten?

What about me?What about me?

Non-Celiac Gluten Sensitivity (say what?)

• Gluten reactions without identified allergic or autoimmune mechanisms • Distress when eating gluten, improvement with GFD

• Occurs within few hours – few days to gluten exposure

• Normal labs • Normal celiac titers (TTG, EMA)• No IgA deficiency• Normal IgE levels, skin prick testing to wheat

• Normal small intestinal biopsies

NCGS is not new….• Cooper, 1980

• Small study of 8 women with abdominal pain, diarrhea and bloating• 6 improved with GFD, but did not have celiac disease

• Karkinen, 2000• 94 adults with abdominal pain after eating gluten• 63% did not have celiac disease

• Within the past 5 years, 2 international consensus meetings (2011, 2012) on gluten-related disorders• Better classifications, so can perform better studies• Identify the questions to be answered

Non-Celiac Gluten Sensitivity Symptoms

Abdominal painDiarrhea

ConstipationNausea/Vomiting

GI

Weight loss

NEURO/PSYCH

Headache

Tingling/Numbness

Brain Fog

Fatigue

Joint painDepression

Bone, joint pain“Fibromylagia”Muscle crampsLeg numbnessLeg tingling

AnxietyDepressionADHD symptoms“Foggy mind”HeadacheBehavioral changesFatigue

Weight lossMouth ulcersRashAbdominal painFlatulenceDiarrheaBloatingAnemia

NCGS – Potential Causes

• Mice with NCGS have increased smooth muscle contractility in the small bowel wall, increased secretion of fluid into the small bowel

• Different composition of gut flora which triggers inflammatory response to gluten

• Certain non-gluten wheat proteins shown to increase immune reactions in the GI tract

• Sensitivity to food additives and preservatives• Nitrates, glutamates, benzoates, sulfites, glutamates

FODMAPs

• Multiple food insensitivities (including wheat) may be due to intakes of high FODMAP foods• Fermentable Oligo-, Di- and Mono-saccharides And Polyols• Poorly absorbed short-chain carbohydrates • Small size, rapid fermentation causes fluid and gas distention • Causes abdominal pain, bloating, diarrhea

• Dairy

• Beans

• CertainCertain Grains, cereals – wheat, rye, barley

• Certain Certain Beans, fruits, vegetables and sweeteners

FODMAPs

And So…..

Celiac Disease vs. Gluten Sensitivity vs. Wheat Allergy

Unnecessary GFD may not be benign……

• Potential of nutritional deficiencies• Low calcium, zinc, phosphorus, iron and B vitamins (folate, niacin, B12)

• Low in fiber – • Fiber protective against heart disease and colon cancer• Fiber protects against constipation

• Loss of prebiotic benefits• Wheat provides 70-80% of Oligofructans, inulin• Prevent against cancer, cardiovascular disease, inflammation

• Wheat may help lower triglyceride and lipid levels (small studies)

Unnecessary GFD may not be benign……

• Inability to diagnosis Celiac Disease• Health complications from not strictly adhering to GFD if

you really do have celiac disease• Self reported adherence to GFD in those even with celiac disease only 45-

81%

Unnecessary hassle (wouldn’t you rather eat that cookie?)• Unnecessary cost (wouldn’t you rather save for a trip?)