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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?