Living Gluten-free in a Gluten-filled World

1. Living Gluten-free in a Gluten-filled World

2. Objectives • Overview of celiac disease and gluten sensitivity • Discuss common nutrient deficiencies • Identify foods to choose • Discuss strategies for navigating the grocery store • Recognize food prep strategies to avoid cross contamination • Cite tools available 2

3. What is Celiac Disease? • Celiac disease (CD) is a genetically linked disease with an environmental trigger. • Eating certain types of protein fractions, commonly called gluten, sets off an autoimmune response that causes damage to the small intestine. 3

4. The Diagnosis for CD – 3 Steps • Physical examine including blood tests for gluten antibodies (IgA based tests) • EMA anti-endomysial • TTG anti-tissue transglutaminase • DGP Deaminated Gliadin Peptide • A small bowel biopsy • Implement the gluten-free diet (process complete when symptoms subside) 4

5. What is non-celiac gluten sensitivity? • Nonallergic and nonautoimmune response • to gluten • Is thought not to cause damage to the small • intestine • Individual tests negative for celiac disease • and wheat allergy but has adverse • response to gluten • Diagnosis remains one of exclusion 5

6. Celiac Disease and Non-Celiac Gluten Sensitivity Celiac Disease Gluten Sensitivity – non-autoimmune (test negative) – non-allergic (test negative) – normal biopsy – complications not known – no consensus on diagnostic criteria – diagnosis remains one of exclusion – autoimmune – IgA, TTG (or others) positive – biopsy shows damage – associated with complications Both respond to the gluten-free diet!

7. CD Prevalence in the U.S. • 1: 133 Average healthy people At Risk Groups: • 1:56 Related symptoms • 1:39 2nd degree relatives (aunt, uncle, cousin) • 1:22 1st degree relatives (parent, child, sibling) Fasano A, et al. Arch Intern Med 2003 Feb 10;163(3):286-92. 7

8. Statistics…..celiac disease • Celiac disease affects at least 3 million Americans • 97% are undiagnosed • The average rate of diagnosis is 4 years Delay causes risk for developing: • autoimmune disorders • neurological problems • osteoporosis • cancer Characteristics of adult celiac disease in the USA: results of a national survey. Green, P.H. et.al. American Journal of Gastroenterology, 2001, 2006. 8

9. Statistics…..gluten sensitivity • Study from Naples, Italy estimates • six percent • of the U.S. population, or 18 million people, suffer from gluten sensitivity (gs) Journal of Internal Medicine Vol 269 No 6, June 2011 Review of May Symposium: Celiac Disease Sapline A . Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity. BMC Med. 2011 Mar 9;9:23.

10. National numbers adding up…….. 3,128,450 1% Celiac Disease (CD) 18,772,705 6% Gluten Sensitivities (GS) __________________________________________ 21,901,000 7% Total Estimate with CD or GS . US Census Bureau as of 8/22/11: 312,045,081

11. Omaha numbers adding up…….. 4,090 1% Celiac Disease (CD) 24,540 6% Gluten Sensitivities (GS) _______________________________________ 28,630 7% Total Estimate in Omaha with CD or GS *Omaha CSA Chapter has 1700 names; assuming 50% contact CSA the diagnosis rates are likely higher in this area . Census Data 2010 for NE and Omaha, 1,826,341 and 408,958 respectively

12. National numbers adding up…….. 3,128,450 1% Celiac Disease (CS) 18,772,705 6% Gluten Sensitivities (GS) __________________________________________ 21,901,000 7% Total Estimate with CS or GS . US Census Bureau as of 8/22/11: 312,045,081 12

13. Symptoms…..over 300 www.csaceliacs.org • GI • Diarrhea or constipation • Abdominal cramping and bloating • Flatus (Passing Gas) • Constipation • Fat in stool • Malabsorption resulting in nutrient deficiencies • Emotional • Depression • Disinterest in normal activities • Irritability • Mood changes • Inability to concentrate

14. Symptoms….. • Other • Anemia • Appetite changes • Decreased ability to clot blood • Decreased fat padding feet/buttocks/hands • Dehydration • Delayed puberty • Edema • Electrolyte imbalance • Fatigue • Glutenataxia (failure of muscle coordination) • Infertility/miscarriages

15. Symptoms….. • Other • Mouth sores or cracked lips • Smooth or geographic tongue • Tooth enamel defects • Muscle cramping (hands and legs) • Night blindness • Nutrient deficiencies • Osteopenia • Osteoporosis • Pain in bones and joints • Very dry skin • Weakness • Weight loss (unexplained) • Dermatitis Herpetiformis

16. Other associated conditions…. Health Hazard Assessment for Gluten Exposure in Individuals with Celiac Disease: Determination of Tolerable Daily Intake Levels and Levels of Concern for Gluten. May 2011. http://www.fda.gov/downloads/Food/ScienceResearch/ResearchAreas/RiskAssessmentSafetyAssessment/UCM264152.pdf • Autoimmune Diseases • Type 1 Diabetes • Thyroid Disease • Addison’s Disease • Sjorgen’s Syndrome • Rheumatoid arthritis • Autoimmune hepatitis • Vitiligo • Raynaud’s Disease • Malignancies • Enteropathic-associated T-cell lymphoma • Small bowel adenocarcinoma • Esophageal squamous carcinoma • Oropharyngeal squamous carcinoma • Dermatitis Herpetiformis

17. Symptoms in Children • How is the child developing? • Slowly • Not gaining weight • Losing weight • Under age three: • Growth failure • Diarrhea • Projectile vomiting • Abdominal bloating/distention • Older children: • Crankiness • Difficulty concentrating • Irritability • Personality changes • Poor memory 17

18. The Diet is the Prescription! Medical Nutrition Therapy Dietitians are the Nutrition Experts 18

19. Three Step Approach A Self-Management Guide to the GF Diet • Step 1 – Foundation • Basic self-management • Begin healing • Make risk-free choices • Choose naturally gluten-free foods • Eliminate wheat, barley, rye, common oats, crosses • and derivatives • Become knowledgeable PreparedbyJean Guest, PhD, RD, LMNT

20. Three Step Approach A Self-Management Guide to the GF Diet • Step 2 – Expansion • Intermediate self-management • Symptoms resolving • Evaluate choices • Address intolerances and allergies • Continue knowledge process

21. Three Step Approach A Self-Management Guide to the GF Diet • Step 3 – Maintenance • Advanced self-management • Habits for optimal health • Evaluate and update plan • Living a full life

22. Most Common Nutrient Deficiencies • Iron • B-12 • Folic Acid • Calcium • Vitamin D • Fiber

23. Sources of Heme-Iron U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp

24. Sources of Non-heme Iron U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp

25. Sources of B-12 U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp

26. Sources of Folate/Folic Acid U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp

27. Food Sources of Calcium U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp

28. Food Sources of Vitamin D U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp

29. Non-Food Sources of Vitamin D • Be sensible!! Don't burn! • 5 - 10 minutes per day • 30 minutes = 20,000 IU's VitaminDHealth.org

30. Food Sources of Fiber Jean E. Guest, PhD, RD, LMNT. Fiber! Fiber! Fiber! CSA Lifeline Volume XXVII, 2007. Tricia Thompson, MS, RD and Suzanne Simpson, RD. Counting Gluten-Free Carbohydrates 2010. Located at http://csaceliacs.org/.

31. Supplement Savvy • GF Multivitamin • GF B-Complex Vitamin • GF Vitamin D • GF Calcium • Talk with your health care team!

32. Where is gluten found?... • wheat • barley • rye • oats (unless gf) • (WBRO) 32

33. Additional sources of gluten…. A gluten-free diet means no: • Wheat • wheat flour, AP flour, wheat bran, wheat starch, wheat germ and other forms of wheat: -Durum -Emmer -Kamut -Semolina -Triticale -Spelt -Einkorn -Graham -Seitan - Bulger - Couscous - Faro 33

34. Gluten-free basic choices • Gluten-free foods include: • Fresh salad (no croutons) • Fruits and vegetables • Milk • Meats, fish or poultry • (no breading, no marinade) • Pure spices and herbs • (watch out for seasonings) • Pasta and breads labeled gluten-free 34

35. Preparing for the grocery store 35

36. FDA’s Proposed Definition of Gluten-Free • Cannot contain wheat, barley, rye (W, B, R)or a crossbred hybrid of these grains • Cannot contain ingredient derived from W, B, R that has not been processed to remove gluten • Can contain an ingredient derived from W, B, R that has been processed to remove gluten but with final product containing < 20 ppm gluten • Must contain <20 ppm or more gluten, whether gluten comes from an ingredient or is in the food unintentionally due to cross contact 36

37. How to know if something is gluten-free? GIG Certification < 10 ppm NFCA Certification <10 ppm Health Canada dictates - 20 ppm is guide CSA Recognition Seal < 5 ppm 37

38. Regulatory Agencies • FDA • Regulates all foods except meat, poultry & egg products • FALCPA covers all packaged foods in the US except those covered by the USDA 38

39. Label reading know how…. Food Allergy Labeling and Consumer Protection Act (FALCPA) requires only top 8 allergens to be identified. Barley, rye, oats and their derivatives are not required to be listed. 39

40. Label reading know how…. • Food Allergy Labeling and Consumer Protection Act (FALCPA) requires the 8 top allergens to be identified. • Barley, rye, oats and their derivatives are not included…keep an eye out for malt and brewers yeast too. 40

41. Regulatory Agencies • USDA • Regulates meat, poultry and eggs • No allergen labeling requirements at this time • If there is a “Contains” statement the manufacturer is voluntarily complying with FALCPA 41

42. Label Reading Savvy Ex 1 Is this nutrition bar gluten-free? • Ingredients: Whole Grain Oats, Maltose Corn Syrup, Sugar, Rice Flour, Almonds, Honey, Dried cranberries, Fructose, Canola Oil, Maltodextrin, Dried Pomegranate Arils, Soy Lecithin, Salt, Malt Extract, Baking Soda, Natural Flavor. CONTAINS ALMOND, SOY; MAY CONTAIN PEANUT AND SUNFLOWER INGREDIENTS 42

43. Label Reading Savvy Ex 2 Modified Food Starch: USDA product may include modified food starch and “wheat” might not be stated on the label Natural Flavorings: USDA product containing protein from W, B, R, the flavoring ingredient must be listed in the ingredients list by its common or usual name Bottom line – call on ? products Frozen Turkey Ingredients: Turkey, Water, Salt, Modified Food Starch, Sodium Phosphates, Natural Flavorings 43

44. Navigating the grocery store • Speciality areas may be located within the store with gluten-free items • Select package items rather than bulk bins • Select products with gluten-free seals whenever possible (especially grains, seeds, and flours*) *Thompson T, Lee AR, Grace T. Gluten contamination of grains, seeds, and flours in the United States: a pilot study. Am Diet Assoc 2010 Jun;110(6):937-40. 44

45. Hidden Sources of Gluten The Three C’s – Content, Contact, Contamination Content - Foods Foods injected with broth Modified food starch Sauces Soy sauce Seasonings Processed foods Cold cuts, deli foods, pre-cooked foods, frozen foods • Breading • Brewer’s Yeast • Broth • Brown rice syrup • Casseroles • Croutons • Gravies 45

46. Hidden Sources of Gluten The Three C’s – Content, Contact, Contamination Content and Contact – Other Items Personal Care Items Lipstick, make up Lotions Medications • Manufacturing • Flour dust in air • Flour on conveyor belts • School • Play dough • Paints • Crayons 46

47. Tips to avoiding cross-contact Separate area and items needed to avoid cross-contact: • Strainers • Utensils, Parchment Paper • Toaster Oven • Designated Prep Area or Station 47

48. What are healthy and tasty gluten-free grains? Brown rice Whole Corn Millet Teff Sorghum Wild Rice Buckwheat Amaranth Quinoa Gluten-Free Oats? Not recommended until 1 year on gluten-free diet ; then self-assessment and antibody testing recommended 48

49. Gluten-Free Sources of Fiber • Almond • Amaranth • Buckwheat • Cornmeal, corn bran • Flax seed and meals, Chia seed • Bean (garbonzo, garfava, black, white, pinto, navy, soy, kidney) 49

50. Gluten-Free Sources of Fiber • Indian wheat grass (Montina) • Millet • Rice bran • Brown rice flour • Soy flour • Teff • Quinoa • Pea Hull Fiber 50