Download Great gluten free living - California WIC Association

Gluten-free Diets and the WIC
Program
Susan Algert, PhD, RD
Nutrition Advisor
University of California Cooperative Extension
Santa Clara County
Objectives:
• What is gluten, who needs to avoid it, and why?
• Where is gluten found in goods, beverages,
cosmetics and medications?
• Which WIC foods can be consumed by gluten
sensitive participants
• Which gluten free foods are most nutritious?
Overview of Presentation
• Update on celiac disease and gluten
intolerance
• The gluten free diet including nutrition tips
• Labeling of gluten free products
Overview of Presentation
• Gluten free WIC foods
• Evaluating gluten free foods on nutrition,
taste and value
• Claims of other benefits of a gluten free
diet
Celiac Disease: Definition
Normal
Celiac Disease
• autoimmune-mediated enteropathy
• caused by ingestion of gluten
• genetically susceptible individuals (high risk groups)
• lifelong disease
Symptoms occur in and out of the GI tract, IF THEY OCCUR AT ALL!!
Celiac Disease: How common is it?
A.
1 in 100,000
B.
1 in 10,000-15,000
C.
1 in 4,000-5,000
D.
1 in 100-200
E.
1 in 10-20
Celiac Disease: How common is it?
A.
1 in 100,000
B.
1 in 10,000-15,000
C.
1 in 4,000-5,000
D.
1 in 100-200
E.
1 in 10-20
In the United States,
in the mid-90’s
Celiac Disease: How common is it?
A.
1 in 100,000
B.
1 in 10,000-15,000
C.
1 in 4,000-5,000
D.
1 in 100-200!!
E.
1 in 10-20
Celiac Disease Epidemiological
Study in USA
Population screened
13145
Healthy Individuals
4126
Risk Groups
9019
Symptomatic subjects
3236
Positive
31
Negative
4095
Prevalence
1:133
Positive
81
Negative
3155
Prevalence
1:40
1st degree relatives
4508
Positive
205
Negative
4303
Prevalence
1:22
2nd degree relatives
1275
Positive
33
Negative
1242
Prevalence
1:39
Projected number of celiacs in the U.S.A.: 2,115,954
Actual number of known celiacs in the U.S.A.: 40,000
For each known celiac there are 53 undiagnosed patients.
A. Fasano et al., Arch Int Med 2003;163:286-292.
Celiac Disease Epidemiological
Study in USA
Population screened
13145
Healthy Individuals
4126
Risk Groups
9019
Symptomatic subjects
3236
Positive
31
Negative
4095
Prevalence
1:133
Positive
81
Negative
3155
Prevalence
1:40
1st degree relatives
4508
Positive
205
Negative
4303
Prevalence
1:22
2nd degree relatives
1275
Positive
33
Negative
1242
Prevalence
1:39
Projected number of celiacs in the U.S.A.: 2,115,954
Actual number of known celiacs in the U.S.A.: 40,000
For each known celiac there are 53 undiagnosed patients.
A. Fasano et al., Arch Int Med 2003;163:286-292.
Celiac Disease Epidemiological
Study in USA
Population screened
13145
Healthy Individuals
4126
Risk Groups
9019
Symptomatic subjects
3236
Positive
31
Negative
4095
Prevalence
1:133
Positive
81
Negative
3155
Prevalence
1:40
1st degree relatives
4508
Positive
205
Negative
4303
Prevalence
1:22
2nd degree relatives
1275
Positive
33
Negative
1242
Prevalence
1:39
Projected number of celiacs in the U.S.A.: 2,115,954
Actual number of known celiacs in the U.S.A.: 40,000
For each known celiac there are 53 undiagnosed patients.
A. Fasano et al., Arch Int Med 2003;163:286-292.
Non-Celiac Gluten Sensitivity:
How common is it?
• 17 million Americans? About 5-6% of the
population
• Official data not available
• Heterogeneous syndrome with treatment of
underlying pathways
• No damage to the small intestine
•How many WIC
participants might have
Celiac Disease or Gluten
Sensitivity?
Celiac Disease - What causes it?
Necessary
Factors
Gluten
Genetics
Gender
Infant feeding
Infections
Others
Pathogenesis
?
Celiac disease
NASPGHAN/CDHNF
Risk
Factors
Grains that Contain “Gluten”
Gramineae
Family
Pooideae
Subfamily
Tribe
Genus
Triticeae
Bambusoideae
Aveneae
Oryzeae
Triticum Secale Hordeum
Avena Oryza
Wheat
Oats
Rye
Barley
Rice
Panicoideae
Andropogoneae
Zea
Maize
Chloridoideae
Paniceae
Sorghum Pennisetum
Sorghum
Millet
Cynodonteae
Eragrostis
Tef
Gluten Sensitivity—What Causes It?
• Activation of the innate immune system
• No damage to the small intestine
• Underlying pathways or causes not well
understood
Dietary Factors- “Gluten”
• ‘Gluten’ is the all-encompassing term for toxic proteins
in celiac disease
• Wheat - (15% protein, 75% starch)
Gluten
Gliadin
Glutenin
(alcohol soluble)
Prolamin
(alcohol insoluble)
• Rye prolamines - secalins
• Barley prolamines - hordeins
Gluten: Seemingly Everywhere
“ I have decided that next to air, water, and dirt,
the next most common substance on the planet
must be gluten.”  -Toni Nolte, Overland Park, Kansas
extracted from Kids with Celiac Disease- Dana Korn
Gluten: Seemingly Everywhere
HUMANS EVOLVED TO EAT MEAT, NOT WHEAT,
AND NO ONE CAN DIGEST GLUTEN…
…BUT NOT EVERYONE GETS CELIAC DISEASE
Gluten- PROLAMINS
• Selected because of agricultural resiliency
• Chemical structure with ideal baking properties
• High in glutamine and proline- immunodominant epitopes, but no
specific peptide activates disease in all patients
• Proline forms helices resistant to digestion in in the mammalian
lumen
• Glutamines can cross-link to give grain resiliency, and the ‘glue’
or gluten that gives bread its shape
Role of Tissue Transglutaminase (TTG)
• Normal gut enzyme
• Released by fibroblasts during injury
• Role in Celiac Disease:
– Modification of gliadin epitopes
• TTG deamidates glutamine residues to glutamic acid
• Deamidation results in higher binding affinity to HLA
DQ2/8 molecule on the surface of antigen-presenting cells
– Autoantibodies against TTG correlate with active
Celiac Disease - ? involved in pathogenesis
The Role of Environmental Factors
in Celiac Disease Pathogenesis***
• Breast feeding reduces the risk of celiac disease and/or at least
delays its onset.
• Introducing gluten at less than 4 months of age is associated
with an increased risk of celiac disease.
• To reduce risk of celiac disease, gluten should be introduced in
small amounts.
• Certain intestinal infections – especially by Rotavirus – increase
the risk of developing celiac disease.
*** very active area of cooperative research
‘Classic’ Presentation of Celiac Disease
• Starts around 6 - 24 months old, after gluten
introduced into diet
• “Malabsorption” Symptoms
–
–
–
–
–
–
Diarrhea
Vomiting
Abdominal pain
Loss of appetite
Failure to thrive
Irritability
CDHNF/NASPGHAN
THE CELIAC ICEBERG
CLASSIC
ATYPICAL
SILENT
LATENT
THE CELIAC ICEBERG
CLASSIC
ATYPICAL
SILENT
LATENT
Celiac Disease Presentation is Changing:
• ATYPICAL (non-gastronintestinal symptoms) are
becoming more TYPICAL
• Nowadays, celiac disease presenting as the classic
malabsorption syndrome is more of an exception,
not the rule, in both children and in adults
• 143 children dx w/ CD 1986-2003
@ Children’s Hospital Wisconsin
• More likely to have non-gastrointestinal
sx, unless less than 4 yo
• 11% of children obese
Telega et.al. Arch Ped Adoles Med. 2008; 162 (2) 164-168
Non-gastrointestinal Manifestations of
Celiac Disease
MOUTH - dental enamel defects, apthous ulceration
GROWTH - short stature
DEVELOPMENT - delayed puberty
MUSCULOSKELETAL – osteopenia, arthritis
CDHNF/NASPGHAN
NEUROLOGIC/PSYCHIATRIC - headaches, ADHD, depression
SKIN - dermatitis herpetiformis
LIVER - inflammation of liver
zdsolutions.it
CDHNF/NASPGHAN
BLOOD - iron deficiency anemia (resistant to iron)
CDHNF/NASPGHAN
CDHNF/NASPGHAN
vitalsigns-health.co.uk
‘Silent Celiac Disease’
X
• No or minimal symptoms, positive serology, and
“damaged” mucosa
• Often found in populations at high risk for celiac
disease
– Close relatives of people with celiac disease
– Other conditions associated with celiac disease
• Type 1 diabetes mellitus (8%)
• Autoimmune thyroid disease
– Other syndromes associated with celiac disease
• Down syndrome (5-12%)
• Selective IgA deficiency (1.7-7.7%)
Celiac Disease ‘Masquerade’
• Patients often receive other diagnoses to explain their
symptoms before being diagnosed with Celiac Disease
• The average delay until diagnosis is 11.7 years
The Canadian Celiac Health Survey Dig Dis Sci 2007Apr; 52 (4) 1087-95
Who may have celiac disease?
(Who should be screened?)
• Patients with persistent GI symptoms
• Patients with non-intestinal symptoms of
celiac disease
• Patients in high risk groups
Complications of Celiac Disease
•
•
•
•
•
Malnutrition
Short Stature
Dermatitis herpetiformis
Dental enamel hypoplasia
Fertility problems
• Osteoporosis
• Gluten ataxia and other
neurological disturbances
• Refractory celiac disease
• Intestinal lymphoma
Mortality rate in patients with untreated celiac disease is TWO FOLD
GREATER at every age (gastrointestinal malignancies)
MOST CAN BE PREVENTED/REVERSED WITH EARLY
DIAGNOSIS AND INITIATION OF GLUTEN-FREE-DIET!
Corrao et.al; Lancet vol 358; 2001
Celiac Disease: How do you diagnose it?
‘‘The most important diagnostic test in CD is the
suspicion of the disease.’’
NIH consensus 2004
Small Intestine
Normal
MARSH
Celiac
After the Diagnosis:
Celiac Disease Treatment
“ I was standing there with my orange juice and
bagel and the doctor said, ‘I’ve got good news
and bad news. That’s your last bagel, but I know
what’s wrong with you’.”
- Heather, 43
(extracted from Celiac Disease: A Hidden Epidemic, Peter H.R. Green and Rory Jones)
How do you diagnose gluten
sensitivity?
Oral gluten challenge test:
• Double blind placebo controlled has highest
diagnostic accuracy but expensive and time
consuming
• Single blind placebo controlled
• Open challenge
Celiac Disease and gluten sensitivity
Treatment:
• Only treatment is a gluten
free diet (GFD)
• Celiac: Strict, lifelong diet
• Gluten Sensitivity: Remove
gluten as much as possible to
avoid symptoms
– Avoid:
• Wheat
• Rye
• Barley
Management of CELIAC Disease
C
E
L
I
A
C
= Consultation with a skilled dietitian
= Education about celiac disease
= Lifelong adherence to GF diet
= Identification/treatment of nutritional deficiencies
= Advocacy group
= Continuous long-term follow-up
NIH Consensus Development Conference Statement, 2004
Dietary management of gluten
sensitivity
• Remove gluten from the diet
• Can reintroduce gluten to see if symptoms
return
• Spectrum of individuals with gluten sensitivity
• Focus on treatment of underlying cause
ADA Evidence based guidelines for
Medical Nutrition Therapy for CD
www.adaevidencelibrary.com
• Assessment of food/nutrition related
history
• Assess biochemical data and results of
medical procedures
• Instruction in the GF diet
• Monitoring and evaluation of dietary
compliance
www.adaevidence library.com
Nutrition Intervention
• Gluten free dietary pattern
• Consumption of whole/enriched GF grains and
products
• Addition of vitamin and mineral supplement
• Inclusion of GF oats as tolerated
• Calcium/vitamin D for reduced bone density
• Iron supplementation for iron deficiency anemia
Nutrition Intervention
• Provide resources and education for
label reading
• Coordination of care
• Education on food cross
contamination
Follow-up and monitoring for
compliance
• Dietary compliance—food record, food label
quiz, expert dietitian evaluation
• Monitoring and evaluation of factors affecting
quality of life
• Monitoring and evaluation of gastrointestinal
symptoms
What to expect after celiac disease
diagnosis is made?
• IF gluten-free diet is adhered to, complications can be
DECREASED / PREVENTED!!
worsening
manifestations of
celiac disease
DECREASE
infertility/miscarriages
increased risk of
GI cancers
refractory celiac
disease
Instructing patients in the
gluten-free diet
• What is celiac disease and importance of GFD
• Sources of gluten in the diet and otherwise
obvious--foods
hidden—1) packaged foods, 2) medications,
supplements, other not so well known sources
3) cross contamination 4) dining out
• Nutrition—1) replacing key nutrients
2) balancing intake
Gluten is the Popular Name for Proteins
that are Present in Certain Dietary Grains
Grain
Scientific Name - Prolamins
WHEAT
GLUTEN
Consists of a mixture of
GLIADINS & GLUTENINS
BARLEY
HORDEINS
RYE
SECALINS
Principle #1—Remove gluten
Obvious Sources
• OBVIOUS SOURCES
–
–
–
–
–
–
–
–
Bread
Bagels
Cakes
Cereal
Cookies
Pasta / noodles
Pastries / pies
Rolls
CDHNF / NASPGHAN
Gluten - Potential Sources
•
•
•
•
•
•
•
•
•
•
Blue cheese (crumbles)
Beer
Broth or bouillon
Candy
Chocolates
Communion wafers
French fries
Herbal teas
Ice cream
Vegetarian burgers
• Licorice
• Malt vinegar
• Maltodextrin (from wheat
starch)
• Medications
• Flavored Nuts
• Puddings
• Salad dressings
• Rice mixes
• Seasonings
• Soy sauce
Examples:
Foods to watch for hidden gluten!
Imitation seafood
Cold cuts
Licorice
Flavored chips & nuts
An Example: Gluten-Free Bread
• One slice of bread is approximately
28 grams or 1 oz.
• To be considered gluten-free, a
slice of bread must contain 0.6
micrograms or less of gluten.
• A person would need to eat more
than 20 slices of gluten-free bread
that contained 20 ppm of gluten to
get too much gluten.
Gluten-free
bread
What is 20 ppm or 20 micrograms?
• One slice of bread is
approximately
28 grams or 1 oz
• 560 micrograms or .6
milligrams per slice of
bread
• 1000 microgms=
1 milligram
Examples of breakfast foods
with GF grains
Nutritious grains.
• Use enriched products to make up for lost
iron and B vitamins
• Buckwheat, millet, amaranth, quinoa, teff
Principle #2
Avoid gluten cross-contamination.
Source of very small amounts of
gluten for most people:
• eating out, food contaminated with gluten or
mislabeled foods
• Minimize contact at home of gluten containing
and gluten free foods
Principle #3
Choose only gluten-free restaurant
menu items.
• Cross-contamination can easily occur in most
restaurants
Example: Oil used to fry
gluten-containing items later
used to fry gluten-free items.
Principle #4
Eat only uncontaminated oats.
• Not all oats can or should
be labeled gluten-free.
• Same guidelines for oats as for other
processed gluten-free grains and starches.
• Buy from companies who test for less than
20 ppm gluten.
#5--Eat a well-balanced
diet rich in vitamins & minerals—
A natural GF diet is not processed!
Target nutrients:
• Iron
• B vitamins
• Fiber
• Magnesium
• Calcium
• Healthy fat such as omega-three fatty acids
Natural Gluten free diet vs
processed gluten free foods
• Natural GF diet shop the periphery of the store
• No need nutritionally for processed GF foods
• $2.3 billion dollar industry in 2010; double from
2006
• Market research has shown that high proportion
of consumers perceive GF foods as “generally
healthier”
2006 Food Allergen Labeling and
Consumer Protection Act (FALCPA)
Must be on labels:
• Are any of the 8 main food allergens contained in a
product
• Main food allergens: milk, egg, peanuts, tree nuts,
fish, shellfish, soy and wheat
• Barley, rye and malt can contain gluten but are not
listed as allergens.
FDA Enforcement
• Testing samples of foods labeled gluten-free
• Inspecting facilities where gluten-free foods are
made
• Reviewing labels to make sure listed ingredients
are gluten-free
Snack chips with correct labeling
Which foods are GF?
•
•
•
•
•
Rice Krispies
Cool Ranch Tortilla Chips
BBQ flavored chicken
Buckwheat Cereal
Oatmeal
Supplements—
• Multivitamin and mineral including B
vitamins, magnesium, zinc, chromium
• Calcium
• Omega-three fatty acids from fish oil
• Vitamin D
Gluten-Free Retail Products
• Gluten-Free (GF) is becoming MAINSTREAM
– GF food industry: >25% growth annually ($700 million in 2006)
– Expected to top $1 billion by 2010
• Labeling Laws improving
• Many local resources
– Natural food market (some have lists of all GF products)
– Specialty bakeries
– Restaurants: many offer GF entrees
Denver Metro Chapter-Celiac Sprue Association
You can have your cake… (GLUTEN FREE)
And eat it too!!
www.buykind.com/images/Gluten_Free_Sugar_Free...
Expert dietitian evaluation of
compliance to diet
• Dietitian evaluates adherence based on:1)
frequency of gluten consumption; 2) behaviors
when dining out; 3) confidence in following the
diet; 4) label reading; 5) cross contamination at
home; 6) use of oats
• Food label quiz
• 3 day food record or recall
Celiac Disease Summary
• Celiac disease is prevalent in US (and through out
the world!!)
• Celiac disease has protean manifestations, in and
out of the GI tract, and can even be ‘silent’
• Celiac disease screening easy, affordable, readily
available
• By diagnosing and treating celiac disease early, can
decrease/reverse complications
• Gluten free diet currently only acceptable treatment
at this time… but future looks bright!
Gluten Sensitivity Summary
• Summary:
• Non celiac gluten sensitivity prevalence is many
times higher than CD in the general population
• Lack of definition is due to heterogeneous
causes of the condition
• Symptoms are caused by different mechanisms
• Management varies due to underlying cause
Which WIC foods are GF
•
•
•
•
•
•
•
•
Kellogs Corn Flakes
Kellogs Rice Krispies
GM Corn Chex
GM Rice Chex
Naturally Gluten free Foods
Oats—which ones?
Gerbers Rice Cereal
Beach Nut Rice Cereal
Is this GF diet balanced for 4 year
old child?
•
•
•
•
•
•
•
•
Breakfast
1 cup Oat cereal
I cup low fat milk
½ banana
Lunch
2 ozs ground beef
5 french fries
3 ozs juice drink
Snack
3 ozs chocolate milk
1 fruit leather bar
Dinner
1 oz chicken
corn tortilla
½ GF krispy rice bar
4 ozs lemonade
Balanced Diet
•
•
•
•
•
•
•
•
Breakfast
¼ cup rice cereal
¼ cup low fat milk
½ banana
Lunch
1 oz GF meat w cheese
1 slice GF bread
Fresh fruit
Snack
2 TBS raisins
2 slices celery
Dinner
1 oz BBQ chicken
3TBS baked beans
¼ cup low fat milk
salad or veggie
Other uses of Gluten free diet
• Irritable Bowel Syndrome (IBS)
• Wheat Allergy
• Weight loss
IBS and gluten free diet
• Study in American J of Gastroenterology; Jan 11
2011
• 34 patients with IBS who did not have celiac
disease.
• Double blind randomized placebo controlled rechallenge study
Results
• Those re-introducing gluten experienced more
pain, bloating and tiredness.
• All patients reported that gluten free diet
reduced symptoms
• Six patients in the gluten challenge group
developed symptoms quickly
Wheat Allergy
• Is there such a
thing as allergy to
gluten?
Allergy to wheat
• Can affect skin, gastrointestinal tract or
respiratory tract
• Symptoms: Hives, nasal and chest congestion,
nausea, vomiting, anaphylaxis
• Prevalence: less than 1 percent of children
• Diagnosis: skin prick, blood, food challenge
• Treatment: avoid wheat products
Autism and Gluten Free Casein free
diet
• Autism Spectrum Disorder (ASD) affects 1 in every 88
children in U.S. (up from 1 in 500 in 1995) CDC
• Autism not associated with increased risk for celiac
disease.
• Autistic individuals do not respond consistently to a
gluten-free and casein-free diet
• A subset of children with autism have GI problems that
respond to dietary/ nutrition intervention
Special Child, Special Diet, www.livingwithout.com
Gluten free diets for weight loss
• Possible health problem can turn into social
health problem as gluten is viewed as “toxic” for
most people.
• What are the health and economic effects of
following a self prescribed gluten free diet?
• Naturally GF diet is rich in fruits and vegetables
so people eat healthier
Is the GF diet a waste of money for
weight loss?
• Avoid highly processed GF foods
• Shop the periphery of the grocery store
• What works best for weight loss currently
References
•
•
•
•
Gluten free Daily—Education and Resources
Find me Gluten Free—Restaurants and reviews
Eating out G Free—Elizabeth Hasselbeck
Tricia Thompson, MS, RD--www.glutenfree dietitan.com
• Melinda Dennis, MS, RDDeletethewheat.com
•Questions?