is ‘gluten free’ really · today the definition of gluten is synonymous with the physiological...

21/07/2020

1

Dr. Kim Faulkner-Hogg

Dietitian, Advanced APD

BSc, Post Grad Dip Nut & Diet, PhD

[email protected]

http://www.glutenfreenutrition.com Brought to you by

Is ‘Gluten Free’ really

100% Gluten Free? Why it matters

▪ Coeliac Disease & Non-Coeliac Gluten Sensitivity (NCGS)

▪ Defining gluten 3 ways

▪ Gluten digestion

▪ Tests to measure background gluten in a gluten free diet

▪ Accidental and contaminant gluten quantified

▪ Toasters, pastas and cakes with shared cooking equipment

▪ In supermarket and restaurant foods

▪ Impact on Quality of Life

▪ Non-Diet therapies to combat contamination

▪ Enzyme therapies to break down undigested gluten

▪ Proposed role alongside the gluten-free diet.

▪ Dietitians role

▪ Points & resources to reduce background gluten exposure

Talk Overview: Gluten

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Non-Coeliac Wheat/Gluten Intolerance▪ Common: 11 %2

▪ Symptoms vary over time▪ Varying avoidance of possible wheat triggers2

▪ Gluten▪ Fructans▪ Lectins▪ Amylase/trypsin inhibitors

Who is avoiding wheat or gluten?28% of Australians monitor their gluten intake 1

▪ 4 % avoid it all together

Coeliac Disease:▪ 1 in 80 males and 1 in 60 females in Australia1

▪ Villi damage and symptoms▪ Lifelong avoidance of all gluten

Defining Gluten

1. Bakers definition:

Gluten:- is the elastic substance that forms when water is added to flour….which stretches and traps gas….allowing the product to rise and be light and porous.

2. Todays definition:Gluten:- is the causative agent for villi damage in those with coeliac disease.

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GLUTEN Containing Grains

▪ Wheat (Spelt, Atta, Durum, Burghul, Khorasan)

▪ Triticale (Hybrid of wheat and rye)

▪ Rye (Pumpernickel)

▪ Barley

▪ Possibly oats: controversial

Listed in decreasing order of gluten quantity

PROLAMIN(Gliadin)

ω

WHEAT STARCH ~<0.02 % gluten

WHEAT

PROTEIN

ALBUMINS

3. How Science Defines Gluten

GLOBULINS

GLUTEN

Water

Sodium Chloride

Ethanol

GLUTELIN(Glutenin)

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Amy C Brown (2012) Expert Review of Gastroenterology & Hepatology, 6:1, 43-55, DOI: 10.1586/egh.11.79

How Coeliac Disease Defines Gluten

Dr. Willem-Karel Dicke, discovered that something in the gluten portion of the wheat grain caused villi destruction in those with coeliac disease

Today the definition of gluten is synonymous with the physiological damage seen in coeliac disease

1940’s

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Gluten is a protein

Amino acids are linked together in different repeating patterns

Proline

Protein

Proteins are strings of amino acids

Glutamine

Gluten containing grains, that can cause damage, have a high proportion of proline and glutamine amino acids in the prolamin portion

GliadinGlutenin

Gluten

What is Gluten?

Picture from: Alessio Fasano. Sci Am. 2009 Aug;301(2):54-61. Surprises from celiac disease.

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GliadinGlutenin

After consumption It is divided into

Peptides

Enzymes in our gastrointestinal track digest proteins into peptides

and single amino acids

Gluten Digestion

GIP: Gluten Immunogenic Peptide▪ Remains toxic to the gut in some

Gluten

Enterocytes

Small intestine – Digested food

SHUT

Pass through

Bloodstream

Inside the lining of the small intestine

SHUT

SHUT

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Enterocytes


Bloodstream


TTG

Intestinal damage

TTG TTG

Restoration of Health3

▪ ↓ symptoms ▪ ↓ antibodies▪ Villi recovery

SymptomsRaised coeliac-specific blood antibodiesInflamed small intestinal mucosa: Villous atrophy

Strict Gluten Free Diet (20ppm)

Diagnoses CD

Gluten Ingestion

Coeliac Disease

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<20ppm United States, Canada and Europe + gluten free oats

20mg gluten/1kg of food

<10ppm Argentina + no oats


<3ppm Australia, New Zealand and Chile + no oats


The term gluten free defines a quantity of gluten that is thought to do no harm

While the details of the standards differ4

Gluten Free Internationally

10mg(aim for <20ppm)

2mg 30mg 50mgPotential small bowel damage

0mg

Mg gluten/day

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mb

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Gluten Free Diets before the year 2000 5,6,7,8,9

▪ daily gluten intake between 5-150mg

▪ Wheat starch

Coeliac Disease Recovery

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0mg

Mg gluten/day

Nu

mb

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of

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10mg gluten daily9

▪ Generally safe for those with CD

▪ International Food Standard aim

Regular ingestion of 50mg daily9

▪ Leads to damage of the small bowel




0mg

Mg gluten/day

Nu

mb

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of

pe

op

le

Symptoms0.15mg gluten

per day10

Biopsy≤7mg gluten

per day10

10mg gluten daily9

▪ Generally safe for those with CD

▪ International Food Standard aim

Regular ingestion of 50mg daily9

▪ Leads to damage of the small bowel


There is a high variability of sensitivity among those with

coeliac disease

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50

~400-500 mg

Gluten Quantities

~50mg gluten = 1/50 of a slice of wheat bread

Using the figure of ~2.5g gluten in a slice of wheat bread

(=2,500mg gluten)

Several crumbs ≡

6 -10 mg gluten

Gluten Quantities

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~ 2.5 g gluten in a slice of wheat bread

Average gluten intake on 20 ppm GFD

is 66 – 108 mg gluten/day

~ 10 mg gluten = 1/250 slice of bread

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Stats vary from paper to paper

Symptoms▪ Despite adherence, there is a high rate of GI symptoms in people on GFD’s 19 .▪ 25-40% of patients have ongoing symptoms despite the GFD20,21,22

▪ Generally those diagnosed as kids have the best outcomes

Probably from trace sources of gluten

Recovery of Coeliac Disease

Villi▪ Most suggest between 30-50% of patients have ongoing villi damage on a GFD 11,12,13,14,15

▪ Slow recovery▪ 4-15% were not recovered at 5 years16,17,18

Adherence to the GFD varies from 36-96%23

▪ Demographic

▪ Psychosocial

▪ Clinical factors

Adherence has 2 main components

▪ Deliberate choice to eat a gluten product

▪ Inadvertent ingestion of gluten

▪ Trace backwards and find the gluten

▪ Background contamination

New tests: detect Gluten Immunogenic Peptides in faeces and urine

Made the theory of background gluten a reality

GIP

Adherence to a GFD

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▪ GIP’s can be detected in urine▪ 4-6 hours after ingesting gluten▪ Remain detectable for 1-2 days

50% of the study group▪ Had positive urine GIPs

Patients with no villi damage:▪ 89% had negative urine GIPs

Patients with villous damage▪ All had detectable urine GIP’s

Morenos’ 2017 study reports11GIP Detection Kits

GIP: Gluten Immunogenic peptides▪ Make it through the intestine unabsorbed▪ Excreted in stool and urine

Developing tests to measure this suggest….▪ Stool:

▪ Detects gluten intakes greater than 40mg/day▪ Could be positive ~2-7 days after ingestion▪ Detects a more chronic exposure

▪ Urine:▪ Detect from about 40-500mg of gluten /day▪ Detects a more accurate exposure

More research is needed to define ▪ Cut off points▪ Conversion factors to gluten consumed▪ Potential gut microbiota influences on GIPs▪ Best uses

Syage 2018 study reports 24

▪ Background gluten ingestion on a GFD was▪ Between 200-400mg gluten/day ▪ Moderate symptoms :- significantly more than

200mg/day

GIP Detection Kits

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Useful in refractory CD if obvious gluten has been excluded ▪ measure if background gluten could be a contributing factor

Research clinical trials▪ Measure compliance

Uses for the GIP test

Caution with use as they could create anxiety

Do not want people to use them after eating at restaurants to say▪ You glutened me!!!▪ Socially and emotionally damaging leading to isolation

Typical Western Diet

10-20g gluten/day25

(ie 10 000- 20 000 mg)

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Some potential sources of contamination of gluten free foods

Hidden in Foods26 Farm, Factory & Market Kitchen/Restaurant/Take-away

Soy sauce Share transport trucks with wheat Self-serve buffets

Beer battered chips Share storage facilities with wheat Toasters

Boost low protein flour Share equipment with wheat Chopping Boards

Salad dressing Unlabelled fresh food Shared cupboard & fridge space

Thickeners Open bulk container foods Shared food crumbs:-jam, butter

Imitation crab Self serve outlets Shared food preparation areas

Gravies and marinades Ambiguous food labels Knives

Confectionary Pasta colanders

Pharmaceutical tablets

May be a reason for symptoms and villi damage

Accidental & Inadvertent Gluten Ingestion

Contamination Potential

Weisbrod V et al. Gastroenterology 2020 Jan;158(1):273-275. doi: 10.1053/j.gastro.2019.09.007

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▪ Shared pop-up toasters OK

▪ Be wary of GF pasta and GF cut cakes

▪ Restaurants

▪ School fetes

Contamination Summary27

OVERALL Cross contamination when cooking is not a huge risk for most people

Country Ref # of products Under 5ppm <20ppm Over 20ppm

n (%) n (%) n (%)

Canada Gelinas 2008 28 77 70 90% 7 9%

Canada Koerner 2013 29 268 265 99% 3 1%

Europe Gibert 2013 30 205 193 94%

USA Sharma 2015 31 275 265 96%

Australia Not R5-Eliza

Forbes & Dods2016 32

169 imported GF foods

169 100%

Italy Verma 2017 33 93 91 98% 2 2%

10 with detectable gluten

Gluten Free in Australia


Not Gluten Free

Food labelled Gluten Free

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Country Ref # of products Under 5ppm <20ppm Over 20ppm

n (%) n (%) n (%)

Finland Collin 2004 34 59 46 75% 13 22%

Canada Gelinas 2008 28 71 55 74.5% 16 22.5%

USA Thompson 2010 35 22 15 68% 7 32%

USA Sharma 2015 31 186 138 74% 12 6% 36 19%

Italy Verma 2017 33 107 99 93% 8 7%

Canada Koerner 201329 298 30 10%

Gluten Free in Australia


Not Gluten Free

Gluten free by ingredientbut not labelled Gluten Free

▪ Foods labelled gluten free are quite safe

▪ Foods not labelled gluten free, but are gluten free by ingredient, are concerning

Conclusions

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91% were gluten free

68% were gluten free

Most contaminated (USA)

▪ Dinner (35%) and breakfast foods (27.2%)

▪ GF pizza meal 53%)

▪ GF pasta meals (50.8%)

GF pizza and GF pasta not good choices to order when eating out

Restaurant MealsMelbourne21:

▪ 158 meals sold as gluten free

▪ Meals tested in a laboratory

USA22:

▪ 5624 meals sold as gluten free

▪ Meals tested by NIMA

Unknowingly, gluten can creep into the background of your diet over a day

Personal symptomtolerance level

Personal villi damagetolerance level

The gluten threshold for inflammation, symptoms and villi damage ▪ varies between people and ▪ may vary over time.

10mg

Contamination build up

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QUALITY OF LIFE: QoL

Strict Gluten Free Diet Adherence

▪ Motivation

▪ Symptom or villi damage…. presence/absence

▪ Long-term medical outcomes

▪ Economic

▪ GF food availability and cost

QoL is a major reason for non-compliance 23, 24

▪ Psychological and emotional needs▪Hypervigilance and anxiety 4, 24

▪Less socializing▪More self-isolation

▪ Social ▪Cultural/Religious ▪Spontaneity▪Travel

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NCGS and CD struggle with social gatherings

Socialising

▪ Hypervigilance

▪ More self-isolation and home cooking

▪ Less restaurants and social food gatherings

▪ Also impacts loved onesRef: 24, 25, 26,27

To live a good QoL for many:-

Diet slip ups and unintentional gluten exposure means the GFD as we live it, is not sufficient to

control symptoms and prevent mucosal damage in some people with coeliac disease and non-

coeliac gluten sensitivity

Quality of Life on a

Gluten Free DietQoL is a balance between

▪ Adherence to a GFD and

▪ Social and emotional well-being

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QoL is a balance between

▪ Adherence to a GFD and

▪ Social and emotional well-being

▪ To assist a gluten free diet

▪ Help to improve quality of life

▪ More socialization

▪ Less symptoms

Non Dietary Therapies 28

Enzyme Therapy 30,31,32

Quality of Life on a

Gluten Free Diet

Current enzymes in research overseas31,32,33

▪ ALV003▪ AN-PEP▪ Kumamax

Enzyme Therapies Under Development

Enzymes can be ▪ engineered or ▪ made from recombinant technologies

or sourced from▪ Fungi▪ Plants; eg

▪ Barley▪ Papaya

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Enzyme Therapies

Caricain in bread making reduced gluten by 90% 49

Caricain Enzyme

Caricain can break down the GIPs left undigested

by human gastrointestinal enzymes 50, 51

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Enterocytes


Bloodstream


Enterocytes


Bloodstream


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Enterocytes


Bloodstream


Proposed protection against background gluten contamination

on a gluten-free diet

▪ Symptom and well-being scores were collected throughout

▪ Intestinal biopsies and blood TTG antibodies collected before and after

Clinical Trials: GluteGuard in Coeliac Disease

2014 & 2016: Trials using GluteGuard

▪ Assessed GluteGuard in Dermatitis Herpetiformis35

▪ Assessed GluteGuard use in Coeliac Disease36

People with Coeliac Disease

▪ 1 gram gluten (1000 mg)

▪ daily for 42 days (6 weeks)

➢ Group 2 received GluteGuard daily

➢ Group 1 received placebo/dummy tablet daily

https://glutagen.com

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No adverse effects of GluteGuard were recorded during the trial

Dummy/Placebo tablet daily

4 of 6 (67%) STOPPED after 14 days due to symptoms

GluteGuard tablet daily

12 of 14 (93%) FINISHED the 42 days


Significantly less symptoms in the group receiving GluteGuard


Study Conclusions

No harmful effects of GluteGuard were recorded during the trial

Fatigue - Nausea/vomiting - Stomach pain - Stomach cramps

Mucosal damage was no worse after 42 days of ingesting 1g gluten daily

8 of 13 who completed 42 days had lower TTG antibodies at the end


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98.5% of GluteGuard users amongst the nearly 300 participants find GluteGuard helpful in providing peace of mind from

symptoms caused by gluten cross-contamination

Survey


Living with Coeliac Disease

▪ Women have more trouble emotionally adapting to a gluten-free diet but,

with time, were more accepting of it than men52.

▪ People need to be provided with appropriate support and resources to enhance their emotional quality of life 53

▪ Difficulties and negative emotions were experienced less often, after more than 5 years on GFD52

▪ Frustration and isolation because of the diet were ongoing negative emotions

▪ Food labelling and eating away from home remained very problematic.

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Patients need to know Patients need to know

What their disease is and what are the long term implications for health

Set up a gluten free kitchen

Join Coeliac Australia Suggest tips for eating out and travel

What is gluten and how it may affect them Alternative product and meal substitutions

Gluten content of ingredients & alternative names Balance the gluten free diet, correct nutrient deficiencies

Teach how to read and interpret a food label Discuss nutrient of concern on a long-term GFD

Purchase Coeliac Australia’s Ingredient List -Mobile App Know the story about oats

Consequence of non-adherence Investigate food intolerances if symptoms persist long term

Dietitian teaching points

https://www.coeliac.org.au/join-now/

RESOURCESTake home: Tips to reduce accidental gluten handout

https://glutenfreenutrition.com.au/

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https://www.coeliac.org.au/join-now/

https://glutenfreenutrition.com.au/

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THIS IS WHAT WE NEED TO AVOID

Finding balance in your gluten free life

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Celiac Patients as Diet Guides Suggest. Gastroenterology, 2020; Jan;158(1):273-275. doi: 10.1053/j.gastro.2019.09.007

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Thank you for attending!

Dr. Kim Faulkner-Hogg

Dietitian, Advanced APD

BSc, Post Grad Dip Nut & Diet, PhD

[email protected]

http://www.glutenfreenutrition.com

61

is ‘gluten free’ really · today the definition of gluten is synonymous with the physiological...

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