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Webinar Title: Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet: What Every Nutrition Professional Needs to Know

Description: Celiac disease is an inherited autoimmune disorder affecting 1-2% of the population. An increased prevalence of celiac disease is seen in other associated disorders such as Type 1 diabetes, autoimmune thyroid and liver diseases, Sjogren’s syndrome and Down syndrome.

Non-celiac gluten sensitivity (NCGS) is another condition thought to be triggered by the ingestion of gluten, although other components in wheat and FODMAP carbohydrates also have been implicated. Due to conflicting research, the lack of diagnostic biomarkers, and overlapping symptoms with celiac disease and IBS, the true prevalence of NCGS is unknown. In addition, it has been found that some individuals with NCGS actually may have undiagnosed celiac disease.

Nutrition professionals need to stay abreast with the latest research about these gluten related disorders in order to effectively manage this growing population. This session will provide evidence-based and practical information about celiac disease and NCGS, including clinical presentations, diagnosis, dietary management; North American gluten-free labeling regulations; nutritional quality and safety of gluten-free products; and client education resources.

Course Objectives: After completing this continuing education course, nutrition professionals should be able to: 1. Identify symptoms and discuss diagnostic challenges in order to differentiate between celiac disease and non-celiac gluten sensitivity. 2. List associated conditions with a high risk for celiac disease. 3. Describe the gluten-free diet including grains/foods allowed and to avoid. 4. Explain the dietary management strategies for celiac disease and non-celiac gluten sensitivity. 5. Discuss the key components of gluten-free labeling regulations and their impact on client education. 6. List key resources and products for clients.

Audience: Registered Dietitians (RD), Registered Dietitian Nutritionists (RDN), Dietetic Technicians Registered (DTR), Nutrition and Dietetic Technicians Registered (NDTR) and members of the interdisciplinary team


Course Continuing Professional Education (CPE) Hours: 1.5 CDR Level: 2

Suggested Learning Needs Codes: 3000: Nutrition Assessment 5000: Medical Nutrition Therapy 5110: Allergies, Sensitivities, Intolerances 5220: Gastrointestinal Disorders

Performance Quality Indicators 8.3.1 – Maintains the knowledge and skill to manage a variety of disease states and clinical conditions 8.3.6 – Keeps abreast of current nutrition and dietetics knowledge and trends 8.4.4 – Considers customers choice, beliefs, food sensitivities, allergies, wants and needs 10.1.3 – Works collaboratively with the interdisciplinary team (including NDTRs) to identify and implement valid and reliable nutrition screening to support access to care

Instructions for Obtaining Continuing Professional Education (CPE): Becky Dorner & Associates is a Continuing Professional Education (CPE) Accredited Provider (NU004) with the Commission on Dietetic Registration (CDR). CDR Credentialed Practitioners will receive 1.5 Continuing Professional Education units (CPEUs) for completion of this activity/material. To obtain the CPE Certificate, each participant must complete a simple evaluation and pass a short test (a grade of 70% is required). You can re-take the test as many times as needed. If you are interrupted and cannot finish the test, simply save the test and come back later to finish it. If you wish, you may also submit evaluations of the quality of activities/materials on the CDR Website at www.cdrnet.org.

A quick way to access the test is through your original order confirmation that you received after placing your order. Scroll towards the bottom and you find the area that says, “To take a TEST, click on the link(s) below”. There should be a link after the text (see highlight on sample to the right of this text). Click on the link, fill in your name to take the test, and receive the CPE certificate. If you are part of a group that purchased additional certificates, the email confirmation will have the same number of links as certificates ordered. The person who received the confirmation can simply email the links to the people who need to take the test. If you are a member on the Becky Dorner & Associates’ website, you can also access the test by logging into the website at www.beckydorner.com. Once you are logged in, click on the left tool bar on the category “Members Only”, then click on “Purchased Tests”. This page has all of the tests that you have purchased from Becky Dorner & Associates. Upon successfully completing the test, you will automatically be directed to the evaluation. Simply enter your email address and complete the evaluation. When finished, click “Submit Survey.” Click on either “print” or “download your certificate” to generate the CPE Certificate with all of the course information including your name.

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Speaker: Shelley Case, BsC, RD is a leading international expert on the gluten-free diet. Shelley is a registered dietitian, author, speaker and consultant with more than 30 years’ experience. She is a member of the Medical Advisory Boards of the Celiac Disease Foundation and Gluten Intolerance Group in the United States; Professional Advisory Council of the Canadian Celiac Association; and serves on the Scientific Advisory Board of the Grain Foods Foundation. Shelley has been featured on radio and television including NBC’s Today show, CBC, CTV and Global TV, as well as frequently quoted in major print media such as the Wall Street Journal, WebMD,

National Post, Globe and Mail, Food Business News, Chatelaine and Canadian Living. A popular speaker, she delivers presentations at medical, nutrition, celiac and food industry conferences throughout North America. Shelley’s best-selling book is highly recommended by health professionals, celiac organizations, consumers and the food industry. Author of many journal articles on celiac disease and the gluten-free diet, she also contributes to a variety of other publications for health professionals and consumers. Her column “Ask the Celiac Expert” is featured in Allergic Living magazine. In recognition of Shelley’s major contributions to the field of celiac disease and her dedication to educating health professionals an individuals with celiac disease in North America, she was awarded the Queen Elizabeth Golden Jubilee Medal. Shelley graduated with a Bachelor of Science Degree in Nutrition and Dietetics from the University of Saskatchewan and completed her Dietetic Internship at the Health Sciences Center in Winnipeg, Manitoba. Over the past 34 years, Shelley has helped thousands of people improve their eating habits and manage a variety of disease conditions through good nutrition. She is founder and president of Case Nutrition Consulting, Inc., a company specializing in celiac disease and the gluten-free diet. Professionally, Shelley is a member of the Dietitians of Canada, Saskatchewan Dietitians Association and the Academy of Nutrition and Dietetics (U.S.), as well as the Nutrition Entrepreneurs, Dietitians in Business and Communications, Food and Culinary Professionals and the Medical Nutrition Practice Groups of the Academy of Nutrition and Dietetics. When she is not sharing her nutrition and health expertise, Shelley is very active in her community and church. She is an accomplished musician who enjoys playing piano and keyboard in her church, at special events and for other occasions. She lives with her husband and daughter in Regina, Saskatchewan, Canada.

Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:What Every Nutrition Professional Needs to Know

Shelley Case, RD, © March 30, 2016 www.shelleycase.comBrought to you by Becky Dorner & Associates, Inc. and Today’s Dietitian CE Learning Library 1

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Shelley Case, RD

Leading international nutrition expert on celiac disease and the gluten-free diet

Popular speaker and educator, Articles have appeared in many

medical journals, magazines, other publications

She has been featured on radio and television including NBC’s Today show and frequently quoted in major print media

Honors: Queen Elizabeth Golden Jubilee Medal

Financial Disclosure

Author and publisher Gluten Free: The Definitive Resource Guide

Scientific Advisory Board Grain Foods Foundation

Celiac Expert Columnist Allergic Living Magazine

Celiac Disease, Gluten Sensitivity & the Gluten-Free Diet:

What Every Nutrition Professional Needs to Know

Shelley Case, RD

Medical Advisory Board:Celiac Disease Foundation

Gluten Intolerance Group of North America

Professional Advisory Council:Canadian Celiac Association

Scientific Advisory Board:Grain Foods Foundation

Author and PublisherGluten Free: The Definitive Resource Guide

Session Highlights

Celiac Disease & Non-Celiac Gluten Sensitivity Gluten-Free Diet Safety of Gluten-Free Foods/Products Cross Contamination Gluten-Free and Food Allergen Labeling Gluten Threshold Levels Nutritional Quality of Gluten-Free Foods Potential New Therapies for Celiac Disease Resources

5Shelley Case, RD 6Shelley Case, RD



Gluten-Free Diet Boom

Latest Fad

Medical Necessity

Celiac Disease

Non-Celiac Gluten Sensitivity (NCGS)

7Shelley Case, RD

Celiac Disease

Affects 1–2% general population, especially Europe, North & South America, Australia

Also common in North Africa, Middle East and South Asia

Can develop at any age including the elderly

Estimated that only 5-15% diagnosed

Many misdiagnosed and/or delay in diagnosis

8Shelley Case, RD

Celiac Disease Inherited autoimmune intestinal disorder

Consumption of gluten triggers an immune reaction

Damage to the small intestinal villi

* Increased intraepithelial lymphocytes (IELs)

* Increased crypt hyperplasia

* Villous atrophy

9Shelley Case, RDCourtesy: Dr. Mohsin Rashid

Normal Celiac Disease

Celiac Disease Multi-system, multi-symptom disease

Results in a wide variety of symptoms and complications if gluten is not completely and permanently eliminated from the diet

10Shelley Case, RD

Gastrointestinal Abdominal pain, bloating, gas

Heartburn or acid reflux

Nausea, vomiting

Diarrhea (mild-severe)

Constipation

Diarrhea/constipation

11Shelley Case, RD

Nutritional Deficiencies

Iron, Folate, Vitamin B12

Calcium, Vitamin D

Other nutrients

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Musculoskeletal

Dental enamel defects

Short stature

Osteoporosis

Bone and joint pain

Arthritis

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Common in children who develop celiac symptoms before age 7

Exact mechanism not clear

immune-mediated damage

nutritional disturbances

Enamel defects vary

color of enamel looks flat (not glazed)

single or multiple cream, yellow or brown opacities

rough enamel surface, horizontal grooves, shallow pits

Dental Enamel Defects

14Shelley Case, RD

Dental Enamel Defects

Oral manifestations of celiac disease: A clinical guide for dentists. Rashid M, et al. J Can Dent Assoc 2011

Classifications of Systemic Dental Enamel Defects in Celiac Disease

Grade 1 Defects in colour of enamel:single or multiple cream, yellowor brown opacities

Grade II Slight structural defects: rough enamel surface, horizontal grooves, shallow pits

Grade III Evident structural defects: deep horizontal grooves, large vertical pits

Grade IV Severe structural defects: shape of the tooth may be changed

Grade IDrs. Ted Malahias & Peter Green

Grade IIDrs. Ted Malahias & Peter Green

Grade IIIChildren’s Digestive Health and Nutrition Foundation

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Short Stature 10-15% of short children and teens have evidence

of celiac disease

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Cutaneous

Mouth Ulcers Dermatitis Herpetiformis

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Courtesy: NASPGHAN

Courtesy: NASPGHAN

Dermatitis Herpetiformis

Only minority (10%) have GI symptoms (mild) 65-75% have small intestinal villous atrophy May also present with other manifestations,

associated disorders and complications (autoimmune diseases, anemia, osteoporosis, malignancy)

Diagnosis - skin biopsy from unaffected skin next to blisters/erosions

Small intestinal biopsy not necessary

Treatment: Strict gluten-free diet for life Dapsone (short term)

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Neurological

Epilepsy

Ataxia

Peripheral neuropathy

Migraine headache

Depression

Behavioral changes

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Reproductive System

Delayed puberty

Menstrual irregularities

Infertility (women and men)

Miscarriage

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Other Presentations

Weight loss (but not always)

CD can occur in overweight or obese individuals

Elevated transaminases

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Clinical Presentations of CD

Symptoms can occur singly or in combination

Vary markedly with age of patient, the duration and extent of disease

Many newly diagnosed adults

DO NOT present with gastrointestinal symptoms

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Associated Conditions with Increased Risk for Celiac Disease

Autoimmune Diseases

Type 1 diabetes

Autoimmune thyroid disease

Autoimmune liver disease

Sjögren Syndrome

Arthritis

IgA nephropathy

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Other Disorders

Down Syndrome

Turner Syndrome

Selective IgA Deficiency

Relatives (1st degree)

2-15%

Shelley Case, RD

Complications of Undiagnosed or Untreated Celiac Disease

Bone disease

Associated health problems related to malnutrition and malabsorption

Increased risk of developing other autoimmune diseases

Increased risk of Non-Hodgkin lymphoma

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Diagnosis ofCeliac Disease

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Diagnosis

Serological Screening Tests

Small Intestinal Biopsy

Must be on a gluten-containing diet

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Serological Screening Tests

IgA tTG (Tissue Transglutaminase)

IgA EMA (Endomysial Antibody)

IgG DGP (Deamidated Gliadin Peptide Antibody)

Total IgA level

* Selective IgA deficiency is more common in

celiac disease than general population

29Shelley Case, RD

Serological Screening

IgA level

*1 to 2% of patients with celiac disease are IgAdeficient compared to general population (0.17%)

30Shelley Case, RD



Reasons for False Negative Celiac Serology Tests

Age < 2 years

Selective IgA deficiency

Reduction or elimination of gluten

Use of corticosteroids or immunomodulator drugs

Possible laboratory error

31Shelley Case, RD

Marsh 0 Normal

Marsh 1-Infiltrative≥25 IEL/100 epithelial cells

Intraepithelial lymphocytosis

Marsh 2- HyperplasticInflammation/villous blunting

Marsh 3aVillous atrophy- Partial

Marsh 3bVillous atrophy - Subtotal

Marsh 3cVillous atrophy - Total


32Shelley Case, RDCourtesy of NASPGHAN

Biopsy Samples

Need a minimum of 4-8 samples

3-4 distal duodenum and 1-3 from duodenal bulb

At least one sample from duodenal bulb increases detection rates in children and adults

Rates of diagnosis continue to increase for every additional biopsy sample taken

33Shelley Case, RD

Kurien M, et al. Gastrointestinal Endoscopy 2012Lebwohl B, et al. Gastrointestinal Endoscopy 2011Rashid M, et al. BMC Gastroenterol 2009


Must be on a gluten-containing diet

If gluten is eliminated or restricted, serological and biopsy tests may be falsely negative

Sensitivity of serology & biopsy diminishes with increased duration on GFD

Gluten challenge (GC)

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Gluten Challenge

Quantity of gluten required and length of time?

No consensus – various protocols

2-5 slices of bread/day for 2 weeks to several months

One slice of bread ranges from 1.5-2.5 g gluten

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Kinetics of the histological, serological and symptomatic responses to gluten challenge in adults

with coeliac disease

Leffler, et al. Gut 2013

20 adults with biopsy-proven CD

Well controlled on a GFD for at least 12 months with no symptoms

Given either 3 or 7.5 grams of gluten/day (2 or 5 slices of bread) for 14 days

Duodenal biopsies (2 weeks prior to GC; Day 3 & 14)

Serological testing (2 weeks prior to GC, Day 0, 3, 7, 14, 28)

Genetic Testing

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2 pts on 7.5g gluten/day developed severe GI symptoms and had to reduce amount of gluten

Results

Significant reduction in Vh:Cd and ”increase” in IEL’s from baseline to day 14

Antibody levels “increased” slightly from baseline to day 14 but markedly by day 28

GI symptoms increased significantly by day 3 No differences seen between 2 gluten doses

\

Kinetics of the histological, serological and symptomatic responses to gluten challenge in adults with coeliac disease

Leffler, et al. Gut 2013

37Shelley Case, RD

Conclusions

14 day GC ≥ 3g gluten/day induces histological & serological changes in over 75% of adults with CD

Celiac antibody response is delayed in comparison with measurable histological changes

Celiac levels continue to rise significantly after the end of gluten challenge

Because no differences seen between 3 and 7.5 g of gluten/day suggests high gluten dose not routinely needed – therefore reduce acute symptoms of GC

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Leffler, et al., Gut 2013

Shelley Case, RD

Gluten Challenge

Leffler study small in size; sensitivity to gluten exposure varied greatly between individuals; and some had no significant serological or histological deterioration after 14 days of gluten exposure

At 4 weeks ~30% did not show measurable serology outcomes for CD

Leffler and others (e.g., Oxentenko & Murray ClinGastro Hepatol 2015) agree that a longer GC period (e.g., 8 weeks) may be necessary to induce serological and histological changes

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Leffler, et al., Gut 2013

Shelley Case, RD

Genetic Tests

HLA alleles associated with CD

DQ2 found in 95% of celiac patients

DQ8 found in remaining patients

DQ2/DQ8 found in 30-40% of general population

High negative predictive value to rule out CD

Negativity for DQ2/DQ8 excludes the diagnosis of celiac disease with 99% confidence

40Shelley Case, RD

Genetic Testing

How to test Cheek swab or blood test

Who to test Close relatives of patients with confirmed CD wanting to

know if they are at risk of developing CD Individuals already on a gluten-free diet Equivocal histology and serology findings in which a

negative genetic test would make CD highly unlikely How often to test

Once in a lifetime Diet

Gluten-free diet will not affect test result

41Shelley Case, RD

Celiac Disease

Strict life-long gluten-free diet currently is the ONLY treatment

Gluten-free diet is very complex

Consultation with a Registered Dietitian with expertise in celiac disease and the gluten-free diet

42Shelley Case, RD




Case report of 43 yr old woman

“Non-coeliac gluten sensitivity?” Ellis A. Lancet 1978

Few reports 1980-2008

Many studies published 2009-2016

3 international consensus conferences to address NCGS

43Shelley Case, RD

Sapone A, et al. BMC Med 2011Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: Celiac disease and gluten sensitivity.

Biesiekierski J, et al. Gastroenterol 2011Gluten causes gastrointestinal symptoms in subjects without celiac disease: A double-blind randomized placebo-controlled trial.

44Shelley Case, RD

Sapone A, et al. BMC Med 2012Spectrum of gluten-related disorders: Consensus on new nomenclature and classification.

Biesiekierski J, et al. Gastroenterology 2013No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed short-chain carbohydrates.

45Shelley Case, RD

Catassi C, et al. Nutrients 2015 Diagnosis of non-celiac gluten sensitivity (NCGS): The Salerno experts’ criteria.

Carroccio A, et al. Am J Gastroenterol 2012Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: Exploring a new clinical entity.

46Shelley Case, RD

Molina-Infante J, et al. Aliment Pharmacol Ther 2015 Systematic review: Noncoeliac gluten sensitivity.

Molina-Infante J, et al. Clin Gastroenterol Hepatol2017Suspected Nonceliac Gluten Sensitivity Confirmed in Few Patients After Gluten Challenge in Double-Blind Placebo-Controlled Trials

De Giorgio R, et al. Gut 2016Sensitivity to wheat, gluten and FODMAPS in IBS: facts or fiction?

47Shelley Case, RD


It is possible to be gluten intolerant and not have celiac disease

Non-autoimmune, non-allergic reaction to gluten

Many symptoms overlap with other conditions

48Shelley Case, RD



Overlapping GI Symptoms

49Shelley Case, RD

Overlapping GI and Extra-Intestinal Symptoms

50Shelley Case, RD

Non-Celiac Gluten Sensitivity (NCGS)“Melting Pot” of Different Patient Groups

Gluten sensitivity

Early-stage celiac disease: “celiac lite”

Misdiagnosed celiac disease

FODMAP intolerance

Other factors?

51Shelley Case, RD


Center for Celiac Research in Baltimore - Dr. AlessioFasano

Saw 5896 patients between 2004-2010 347/5896 patients - 6% fulfilled criteria for NCGS Symptoms

Abdominal pain (68%) Eczema and/or rash (40%) Headache (35%) “Foggy mind” (34%) Fatigue (33%) Diarrhea (33%) Depression (22%) Anemia (20%) Numbness legs/arms/fingers (20%) Joint pains (11%)

52Shelley Case, RD


Negative CD serology (TTG or EMA)

IgA deficiency ruled out

AGA antibodies may be positive

HLA DQ2 or DQ8 may be present

Intraepithelial lymphocytosis without villous atrophy

53Shelley Case, RD

Intraepithelial Lymphocytosis Increased lymphocytes in villous epithelial lining

Number of IEL’s can increase due to variety of immunologic stimulants: Gluten related disorders (CD, NCGS, wheat allergy) Non-gluten food hypersensitivity (e.g., cow’s milk, soy) Drugs (e.g., NSAID’s, PPI’s) Infections (e.g., H. pylori, Giardia) Bacterial overgrowth IBD Lymphocytic and collagenous colitis Immune dysregulation (e.g, RA, Graves, Hashimoto’s

thyroiditis, Lupus, MS) IBS

54Shelley Case, RDLauwers G, et al. Modern Pathology 2015



Food For Thought…

Non-Celiac Gluten Sensitivityvs

Celiac Disease

55Shelley Case, RD

Characterizations of Adults with a Self-Diagnosis of Nonceliac Gluten Sensitivity

Biesiekierski J, et al. Nutr Clin Pract 2014

It is possible NCGS patients may actually have undiagnosed celiac disease

Surveyed 248 people who believed they had NCGS

147 completed survey

Mean age 43 years

88% female

62% were not properly excluded for celiac disease Many that had a biopsy were on a gluten-free diet 15% had no serological/HLA tests or intestinal biopsy

56Shelley Case, RD

Characteristics of Patients Who Avoid Wheat and/or Gluten in the Absence of Celiac Disease

Tavakkoli A, et al. Dig Dis Sci 2014

Patients who avoid wheat and/or gluten (PWAWG) are a heterogeneous group; predominately self-diagnosed before presenting to physician office

Cross-sectional study at Celiac Center at Columbia University in NYC

Retrospective analysis compared three patient groups: 84 PWAWG 585 Celiac disease 2686 NHANES

Baseline characteristics, lab values, medical co-morbidities

57Shelley Case, RD

Characteristics of Patients Who Avoid Wheat and/or Gluten in the Absence of Celiac Disease

Tavakkoli A, et al. Dig Dis Sci 2014

PWAWG…

57/84 (68%) received endoscopy 28/57 (49%) on GF diet at time of endoscopy Median time on GF diet at time of endoscopy was 1

year

32 alternative diagnoses made in 25 (30%) SIBO (16) Fructose intolerance (5) Lactose intolerance (3) Other Food intolerances (3) Microscopic colitis (3) Gastroparesis (1) Pelvic floor dysfunction (1)

58Shelley Case, RD

Intestinal Cell Damage and Systemic Immune Activation in Individuals Reporting Sensitivity to

Wheat in the Absence of Celiac Disease

Uhde M, et al. Gut 2016 Three groups of patients:

Reported symptoms from wheat (celiac disease and wheat allergy ruled out)

Celiac disease

Healthy controls

Analyzed sera for markers of intestinal damage and systemic immune response to microbial components

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Uhde M, et al. Gut 2016

Pts with sensitivity to wheat in absence of CD:

Significantly increased serum levels of soluble CD14 and lipopolysaccharide (LPS)-binding protein; antibody reactivity to bacterial LPS and flagellin;

Significantly elevated fatty acid-binding protein 2 (FABP2)

– marker of intestinal epithelial cell damage Significant change towards normalization of the levels

of FABP2 and immune activation markers in a subgroup of pts with wheat sensitivity on a diet free of wheat and related grains

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Uhde M, et al. Gut 2016

Study did not “address the mechanism or molecular triggers responsible for driving the presumed loss of epithelial barrier integrity and microbial translocation.”

Further studies needed

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Gluten or Other Components in Foods

Controversial whether it is gluten or other components in wheat such as fructans which are part of FODMAP’s that may cause symptoms

FODMAP’s are short-chain, rapidly fermented carbohydrates that can trigger GI symptoms in some patients

F = fermentableO = oligosaccharides (fructans and galacto-oligosaccharides)D = disaccharides (lactose)M = monosaccharides (fructose)A = andP = polyols (sorbitol and mannitol)

62Shelley Case, RD

FODMAP’s

* Wheat, rye and barley contain:- fructans (CHO) - gluten (protein)

FODMAP CHOs EXAMPLES

Fructans - Barley*, Rye*, Wheat*- Artichoke, Chicory Root, Dates, Figs, Garlic, Inulin, Leek, Onion, Watermelon

Galactans Black Beans, Chickpeas, Kidney Beans, Lentils, Soybeans

Lactose Ice Cream, Milk, Soft Cheeses

Fructose - Agave, High-Fructose Corn Syrup, Honey, - Fruits (Apple, Cherry, Mango, Peach, Pear, Prune, Watermelon)- Vegetables (Artichoke, Asparagus, Sugarsnap Peas)

Some Fruits/Vegetables and Sugar Alcohols

- Fruits (Apples, Apricot, Blackberry, Nectarine, Peach, Pear, Plum, Prune, Watermelon)- Vegetables (Cauliflower, Button Mushroom, Snow Peas, Sweet Corn)- Maltitol, Mannitol, Sorbitol, Xylitol

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Key Points Need to rule out CD and wheat allergy

NCGS: Heterogeneous group with several subgroups GI and non-GI symptoms Prevalence rates highly variable Pathophysiology is poorly understood No biomarkers for diagnosis Need rigorous prospective randomized DBPC studies

Use purified gluten vs wheat-based foods (gluten, non-gluten proteins, fructans)

Treatment of NCGS? Gluten-free diet Temporary low FODMAP Diet Other?

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Questions “GLUTEN”

General name for specific proteins (prolaminsand glutelins) in the grains wheat, rye, barley

Challenge because gluten-containing grains found in a wide variety of foods and beverages

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Avoid Barley Bulgur Couscous Durum Einkorn* Emmer* Farro* Kamut* Malt** Malt Extract** Malt Flavoring**

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Malt Vinegar** Regular Oats *** Rye Semolina Spelt (Dinkel)* Triticale Wheat Wheat Bran Wheat Flour Wheat Germ Wheat Starch****

* Types of wheat** Derived from barley*** Often contaminated with wheat/barley/rye**** Unless specially processed Shelley Case, RD

Frequently Overlooked Items That May Contain Gluten

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Corn and rice cereals

Sauces, soy sauce, salad dressings, marinades

Seasonings, specialty prepared mustards

Breading, stuffing, gravy

Soups, soup bases, broth, bouillon cubes

Meat loaf, sausages, hot dogs, other processed meats, burgers (beef, fish, chicken)

Meat substitutes (vegetarian burgers, textured vegetable protein)

Self-basting poultry, imitation seafood

Shelley Case, RD

Frequently Overlooked Items That May Contain Gluten

Baked beans, dry roasted or flavored nuts

Seasoned rice mixes and rice pilafs

Seasoned potato chips, corn chips and other snack foods

Chocolate bars, chocolates, licorice

Flavored and herbal teas, flavored coffees, coffee substitutes

Beer, ale and lager

Communion wafers

69Shelley Case, RD

Frequently Questioned Ingredients

Vinegars

Barley Grass & Wheat Grass

Autolyzed Yeast / Yeast Extract

Barley Malt

Caramel

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Frequently Questioned Ingredients

Spices, Herbs & Seasonings

Wheat Starch

Modified Food Starch

Dextrin

Maltodextrin

Glucose Syrup

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Alcohol

Distilled Alcohols

Liqueurs

Wine

Beers

Gluten-Containing

Gluten-Reduced

Gluten-Free

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Naturally Gluten-Free Foods

Plain meat, fish, poultry, eggs, nuts, seeds, pulses

Milk, most yogurt and cheese products

Fruits and vegetables

Butter, margarine, oils

Sugars, honey, molasses

Cereals, pasta, breads and other baked products made from gluten-free alternatives

Gluten-free grains (pure, uncontaminated)

73Shelley Case, RD

GF Grains, Seeds, Flours & Starches

Arrowroot Amaranth Buckwheat Corn Flax Mesquite flour Millet Nut flours (almond,

hazelnut, pecan) Oats (pure,

uncontaminated) Potato Starch, Potato Flour

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Pulses/Pulse flours (beans, chickpeas, lentils, peas)

Quinoa Rice (black, brown, purple,

red, white, wild) Rice Bran Sorghum Soy Tapioca Teff

Shelley Case, RD

Safety ofNaturally Gluten-Free

Grains, Flours, Starches and Seeds

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Gluten Contamination in Oats

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Courtesy of Farm & Food Care Saskatchewan

Gluten Contamination in the Canadian

Commercial Oat SupplyKoerner TB, et al. Food Additives and Contaminants 2011

93% samples were over 20 ppm (21-3784)

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Type of Oat Range (ppm)

Median(ppm)

Mean(ppm)

Steel-cut oats 55-1467 660 645Rolled/flaked/oatmeal 0-2485 81 316Quick/minute oats 13-3784 534 655Oat bran 37-3469 280 704

Shelley Case, RD

Gluten Equivalents

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20 ppm = 20 mg/kg = 2 mg/100 g

100 ppm = 100 mg/kg = 10 mg/100g

Shelley Case, RD

ppm mg/kg mg/100 g20 20 2100 100 10

SG1



Gluten Detection in Foods Available in the United States: A Market

SurveySharma G, et al. Food Chemistry 2015

FDA investigated extent of gluten cross-contamination GF labeled foods (275) Non-GF labeled foods without wheat/rye/barley in

the ingredient list (186)

Analyzed products Ridascreen R-7001 Gliadin ELISA Morinaga wheat protein sandwich ELISA

Samples from local grocery stores

79Shelley Case, RD

Gluten Detection in Foods Available in the United States: A Market Survey

Sharma G, et al. Food Chemistry 2015

Gluten-Free Label Claim No Gluten-Free Label Claim

Total Samples 275 186

Gluten Range ppm 5.8-554 5.3-1566

Products > 20 ppm 3/275 (1%) 36/186 (19.4%)

Products > 100ppm 1 out of the 3 above 19 out of the 36 above

Wheat/Gluten Advisory Statement on

Label

> 20ppm

29/275 (10.5%)

1/29 (3.5%)

53/186 (28.5%)

18/53 (34%)

12 cereals3 grains/seeds/legumes/nuts

2 granola/bars1 snack food

Products with Oats

> 20 ppm

11/275 (4%)

1/11 (9%)

44/186 (23.7%)

29/44 (66%)

80Shelley Case, RD

Gluten Contamination of Naturally Gluten-Free Flours & Starches Used by Canadians with Celiac

Disease

Koerner T, et al. Food Additives and Contaminants 2013

Health Canada investigated extent of gluten cross-contamination in naturally gluten-free flours & starches (no oat products)

Analyzed 640 samples for gluten

Samples from 8 Canadian cities between 2010-2012

Grocery stores, health food stores and internet stores

Products from Canada, USA, Europe & other countries

640 samples ranged from 5-7995 ppm

9.7% (62/640) samples > 20 ppm

81Shelley Case, RD

Claims on Package# Samples> 20 ppm

Percentage (%)

Gluten-Free 3/268 1.1

No Gluten-Free Statement 30/298 10

Gluten Precautionary Statements

29/74 39.2

TOTAL 62/640 9.7%

Koerner T, et al. Food Additives and Contaminants 2013

82Shelley Case, RD

Gluten Contamination of Naturally Gluten-Free Flours & Starches Used by Canadians with

Celiac Disease

Recommendations for Purchasing Gluten-Free Specialty Products

83Shelley Case, RD

Choose gluten-free flours, starches, mixes, baked products, cereals and pastas from companies:

Labeled “gluten-free” Good manufacturing practices with rigid quality control Protocols test ingredients and final products for gluten using

appropriate methods

Avoid buying from bulk bins or stores that buy products in bulk and re-package into smaller containers because the area and equipment can easily be cross-contaminated with gluten-containing items.

SG2

Cross Contamination

Store all GF products in separate labeled containers

Separate location in the cupboard for GF foods

Store GF flours and grains in the cupboards above gluten containing foods. Flour dust and bread, cookie and cracker crumbs can easily end up on GF containers and boxes if you are not careful

Separate butter/margarine, jam, peanut butter containers

Use squeeze bottles of condiments and salad dressings

Buy bright stickers and put on gluten-free items especially flours, starches, jam, peanut butter, etc.

84Shelley Case, RD



Cross Contamination

Wash counter tops, cutting boards and microwave frequently

Thoroughly wash pots, utensils and baking pans

Separate utensils and GF baking items (e.g., sifter, wooden spoons, muffin tins, cookie sheet)

Separate pasta colander

Separate bread machine

85Shelley Case, RD

Cross Contamination

Separate toaster

Toaster oven

Toaster bags

86Shelley Case, RD

Gluten-free

SG3

Food Labeling

87

“Personally, I don’t touch anything without first having a look at the list of ingredients.”

(Guidelines For A Gluten-Free Lifestyle – Celiac Disease Foundation) Shelley Case, RD

USA

Gluten-Free Labeling

88Shelley Case, RD

“Gluten-Free Labeling of Food”CFR Part 101, Section 101.91 (21 CFR 101.91)

FDA final rule August 5, 2013 Voluntary use of a gluten-free claim

Applies to:- Packaged foods- Dietary supplements- Infant formulas- Medical foods- FDA regulated alcoholic beverages

Does not apply to:- USDA regulated products- TTB regulated alcoholic beverages- Cosmetics, prescription and non-prescription drugs

89Shelley Case, RD

Allowed terminology:- Gluten-free- No gluten- Free of gluten- Without gluten

Product must be less than 20 ppm gluten Prohibited grains

- Wheat- Barley- Rye

Oats sold as a single ingredient must be < 20 ppm When oats used in a multi-ingredient food, final product

must be < 20 ppm. Oats do not have to be specially produced to be used as ingredients in foods labeled “gluten free”.

90Shelley Case, RD




“Gluten-containing grain” means any one of the following grains or their crossbred hybrids:

- wheat, rye and barley

91Shelley Case, RD


92Shelley Case, RD


“Gluten-free” means the food is:

* Inherently gluten free OR

* Does not contain an ingredient that is:- An ingredient that is a gluten-containing grain (e.g., spelt wheat)- Derived from a gluten-containing grain that has not been processed

to remove gluten (e.g., wheat flour)- Derived from a gluten-containing grain that has been processed to

remove gluten (e.g., wheat starch), if the use of that ingredient results in the presence of 20 ppm or more gluten in the food

* Any unavoidable presence of gluten in food must beless than 20 ppm

CANADA

All priority allergens and gluten sources must be declared on the label of

pre-packaged foods

“1220 - Enhanced Labelling For Food Allergensand Gluten Sources and Added Sulphites”

93Shelley Case, RD

Priority Allergens Wheat or triticale Peanuts Almonds, Brazil Nuts, Cashews,

Hazelnuts, Macadamia Nuts, Pecans, Pine Nuts, Pistachios or walnuts

Milk Eggs Soybeans

Crustaceans Shellfish Fish Sulphites (> 10 ppm) Sesame Seeds Mustard Seeds OR any protein, modified

protein or protein fraction from any of the above foods

Barley Rye Wheat Triticale Oats* OR any gluten protein, modified gluten protein or gluten protein

fraction from any of the above cereals

Definition of Gluten

94Shelley Case, RD

Gluten-Free Regulation

Revised February 16, 2011 with Schedule 1220

“Gluten-Free” B.24.018

“It is prohibited to label, package, sell or advertise a food in a manner likely to create an impression that it is a gluten-free food if the food contains any gluten protein or modified gluten protein, including any gluten protein fraction, referred to in the definition of “gluten” in subsection B.01.010.1 (1).”

95Shelley Case, RD

B.01.010.1 (1)

“gluten” means

(a) any gluten protein from the grain of any of the following cereals or from the grain of a hybridized strain that is created from at least one of the following cereals:

(i) barley,(ii) oats,(iii) rye,(iv) triticale,(v) wheat; or

(b) any modified gluten protein, including any gluten protein fraction, that is derived from the grain of any of the cereals referred to in paragraph (a) or from the grain of a hybridized strain referred to in that paragraph. (gluten)

96Shelley Case, RD



Health Canada’s Position on Gluten-Free Claims

Only the term “gluten free” is allowed

Gluten-free foods must not exceed 20 ppm gluten threshold

97Shelley Case, RD

2015

98

Marketing AuthorizationExemption from Food & Drug

Regulations The food contains no oats other than specially

produced “gluten-free oats”

Do not specify the method or controls to should use to produce gluten-free oats

Finished product does not contain greater than 20 ppm of gluten from wheat, rye, barley, or their hybridized strains

The “gluten-free oats” are clearly identified as such in all cases where ‘oats’ are referenced, including the list of ingredients

99Shelley Case, RD

Gluten-Free Oat Production

100

Purity Protocol

Cleaned Commodity Oats

Dedicated Fields(no wheat, rye or barley)

Yes No

Pure Oat Seed Yes No

Field Inspections Yes No

Dedicated or Thoroughly Cleaned Equipment

Yes No

Dedicated Mill for Processing

Yes Variable

Frequent Gluten Testing Yes Variable

Shelley Case, RD

Definition of the “Purity Protocol” for Producing Gluten-Free Oats

Accepted for publicationhttp://dx.doi.org/10.1094/CCHEM-01-17-0017-VO

www.gluten.org

“Consensus definition of the Purity Protocol requirements based on input from the four largest Purity Protocol oat processors in North America. This definition provides transparency to gluten-free consumers and allows for auditing of Purity Protocol claim.”

Dr. Laura K Allred, Gluten Intolerance Group of North America, GFCOMs. Cynthia Kupper, Gluten Intolerance Group of North America, Mr. Gary Iverson, Montana Gluten Free, Mr. Tracy B. Perry, Cream Hill Estates, Ltd.Mr. Seaton Smith, GF Harvest / Canyon OatsMr. Robert Stephen, Avena Foods Limited

Shelley Case, RD101

1-3 wheat or barley kernels/kg of oats....

> 20ppm

1 kg oats = 20,000 – 25,000 kernels

Contamination of Gluten-Free Oats

102Shelley Case, RD



Guidelines for Incorporating Oats in the Gluten-Free Diet

103Shelley Case, RD

Celiac disease should be well controlled Celiac antibody levels normalized Symptoms resolved

Use pure, uncontaminated gluten-free oats Start with small amounts Gradually increase as tolerated

Oats are high in fiber Changes in stool pattern and/or possible GI symptoms

Reaction to oats Few case reports of intolerance to pure, uncontaminated oats Eliminate oats and consider re-challenge If reaction during re-challenge contact MD Consultation with dietitian to evaluate and ensure no hidden

gluten104

Overview of Guidelines for Introducing Oats

Shelley Case, RD

Safety IssuesGluten Threshold Levels

105Shelley Case, RD

Gluten Threshold in GF FoodsIT TAKES TWO TO TANGO!

The daily gluten intake is the product of gluten ppm in food and daily intake of wheat substitutes

Then the decision on the gluten threshold in GF food must take into account the variable intake of wheat substitutes

106From Dr. Alessio Fasano

Intake of Gluten and ppm of Gluten in Food

50 g 100 g 200 g 300 g

200 ppm 10 mg 20 mg 40 mg 60 mg

100 ppm 5 mg 10 mg 20 mg 30 mg

50 ppm 2.5 mg 5 mg 10 mg 15 mg

20 ppm 1 mg 2 mg 4 mg 6 mg

107Catassi et al. Am J Clin Nutr. 2007;85:160-6 Shelley Case, RD

Multicenter, DBPC randomized trial 49 adults with biopsy-proven celiac disease; 39 completed

study On strict GFD for > 2yrs Given capsule with 0, 10 or 50 mg gluten/d for 3 months Clinical symptoms, blood and biopsy tests before and after

study Large individual variability in the sensitivity to traces of

gluten 50 mg/d produced significant damage in the small

intestinal mucosa One patient developed symptoms at 10 mg/d Conclusion: “The ingestion of contaminating gluten should

be kept lower than 50 mg/d in the treatment of CD.”108Shelley Case, RD

Gluten Threshold StudyCatassi et al. Am J Clin Nutr. 2007;85:160-6



Intake of Gluten and ppm of Gluten in Food

50 g 100 g 200 g 300 g

200 ppm 10 mg 20 mg 40 mg 60 mg

100 ppm 5 mg 10 mg 20 mg 30 mg

50 ppm 2.5 mg 5 mg 10 mg 15 mg

20 ppm 1 mg 2 mg 4 mg 6 mg

Catassi et al. Am J Clin Nutr. 2007;85:160-6 109Shelley Case, RD

The Dose-Effect Response (typical CD cases)

From Dr. Alessio Fasano 110

Nutritional Quality of Gluten-Free Foods

and Specialty Products

111Shelley Case, RD

Gluten-Free Product Formulations

White rice flour, corn starch, potato starch and tapioca starch are the staples for baking and in most GF specialty products

Many gluten-free products:

higher in carbohydrate, sugar, fat & calories

lower in fiber, B vitamins, iron, protein

not enriched with iron and B vitamins like their gluten-containing counterparts

112Shelley Case, RD

Oat Nutrition

Source of dietary fiber, both soluble (β-glucans) and insoluble fibers

B-complex vitamins: thiamin, niacin and riboflavin

Iron

Protein

113Shelley Case, RD

Oat Power

114

Oat Flour Oat Bran White Rice Flour

Tapioca Starch

Cornstarch Potato Starch

Protein (g) 18 16 9 0 0.3 0.2Fiber (g) 11 15 4 0 1 0

Carbohydrate (g) 79 62 127 106 117 158

Iron (mg) 7.7 5.1 0.6 0 0.6 2.9

Calcium (mg) 66 55 16 28 3 19Zinc (mg) 2.6 2.9 1.3 N/A 0.1 N/A

Magnesium (mg) 83 221 55 N/A 4 N/A

Thiamin (mg) 0.8 1.1 0.22 N/A 0 0

Riboflavin (mg) 0.13 0.21 0.03 N/A 0 0

Folate (mcg) 65 49 6 N/A 0 N/A

* Chart excerpted from Gluten Free: The Definitive Resource Guide by Shelley Case, RD** Nutrient Information based on one cup of flour Shelley Case, RD



Gluten-Containing vs. Gluten-Free Flour Comparison

Enriched White Flour

Whole Wheat Flour

White Rice Flour

Tapioca Starch


Protein (g) 13 16 9 0 0.3 0.2

Fiber (g) 3 13 4 0 1 0

Carbohydrate (g) 95 86 127 106 117 158

Iron (mg) 5.8 4.3 0.6 0 0.6 2.9

Calcium (mg) 19 41 16 28 3 19

Zinc (mg) 0.9 3.1 1.3 N/A 0.1 N/A


Thiamin (mg) 0.98 0.6 0.22 N/A 0 0

Riboflavin (mg) 0.62 0.2 0.03 N/A 0 0


* Chart excerpted from Gluten Free: The Definitive Resource Guide by Shelley Case, RD** Nutrient Information based on one cup of flour 115Shelley Case, RD

GF Grains, Seeds, Flours & Starches

Greater variety of grains, seeds and flours in gluten-free products:

Better flavor and texture

Improved nutritional profile

116Shelley Case, RD

Pulse Power

Pulses and Pulse Flours (Legumes)

Nutrient dense

fiber, protein, B vitamins, iron, other minerals and vitamins

Low glycemic index

Low in fat

Economical

117Shelley Case, RD

SG4

Pulse PowerChickpea (Garbanzo

Bean) Flour

Yellow Pea Flour

White Rice Flour

Tapioca Starch


Protein (g) 26 41 9 0 0.3 0.2

Fiber (g) 18 21 4 0 1 0

Carbohydrate (g) 67 105 127 106 117 158

Iron (mg) 6.3 8.0 0.6 0 0.6 2.9

Calcium (mg) 85 134 16 28 3 19

Zinc (mg) 3.2 5.4 1.3 N/A 0.1 N/A


Thiamin (mg) 0.64 1.08 0.22 N/A 0 0

Riboflavin (mg) 0.14 0.22 0.03 N/A 0 0


* Chart excerpted from Gluten Free: The Definitive Resource Guide by Shelley Case, RD** Pulse flours analyzed by Silliker Canada June 2010*** Nutrient Information based on one cup of flour 118Shelley Case, RD

www.pulsecanada.com

119Shelley Case, RD

Almond Flour PowerBlanched

Almond FlourNatural

Almond FlourWhite Rice

FlourTapioca Starch


Protein (g) 24 21 9.4 0 0.3 0.2

Fiber (g) 11 13 3.8 0 1.2 0

Carbohydrate (g) 21 22 127 119 117 158

Iron (mg) 3.7 3.7 0.6 0 0.6 2.9

Calcium (mg) 264 269 16 0 3 19

Zinc (mg) 3.3 3.1 1.3 0 0.1 N/A

Magnesium (mg) 300 270 55 0 4 N/A

Riboflavin (mg) 0.8 1.14 0.03 0 0 0

Niacin (mg) 3.9 3.6 4.1 0 0 0

* Chart excerpted from Gluten Free: The Definitive Resource Guide by Shelley Case, RD** Nutrient Information based on one cup of flour 120Shelley Case, RD



Healthy Gluten-Free Diet Tips

Choose naturally gluten-free, nutritious foods

Lean meat, poultry, fish, eggs, nuts, seeds, fruits, vegetables, pulses (legumes), low fat dairy products, whole grains

Increase intake gluten-free whole grains

Amaranth, buckwheat, millet, oats, quinoa, sorghum, teff, rice (black, brown, red, wild)

121Shelley Case, RD


Fiber-rich foods

Iron-rich foods

Calcium-rich foods/beverages

Vitamin D-rich foods/beverages

122Shelley Case, RD


Compare gluten-free specialty products

Review ingredients and nutrition facts table

Limit products high in sugar, fat and calories

Choose products:

healthy whole grains

enriched/fortified

more protein, fiber, vitamins/minerals

123Shelley Case, RD

Alternative Therapies

124Shelley Case, RD

Why Alternatives to GFD Needed?

GFD is challenging and expensive

Gluten contamination – eating out, food manufacturing, etc.

Up to 60% of adult pts are symptomatic despite GFD

Incomplete healing of intestinal mucosa in many pts

Evidence of persistent mucosal inflammation

Mucosal recovery post-diagnosis Adults: 34% at 2 years; 66% at 5 years; 90% at 9

years Children: 95% by 2 years; 100% long-term

Persistent symptoms

125Slide adapted from Verdue, EF. McMaster University Shelley Case, RD

Alternative Therapies in Celiac Disease

New strategies for treating celiac disease are currently being researched

Celiac Safe Wheat

Gluten Sequestering Polymers

Antigen Presentation Suppressors

Modulation of Inflammatory Response

Vaccines

Enzyme Therapies

126Shelley Case, RD



Commercial Enzyme Supplements

Different from purified supplements used in clinical trials

OTC enzyme supplements destroyed by acid and pepsin in the stomach

Cannot break down gliadin peptides in the stomach before they reach the small intestine

Research has shown these commercial supplements are not effective and should not be used by those with CD or NCGS

127Shelley Case, RD

Resources

128Shelley Case, RD

Gluten Freedom


* CD, DH, NCGS* Foods & ingredients allowed and to avoid* Frequently questioned ingredients* Oats* Alcohol* Gluten threshold levels, ppm & testing* GF food labeling in the US & Canada* Nutrition* GF meal planning* GF shopping/shopping list* Cross-contamination at home & away from home* GF cooking & baking* Recipes* GF product listing by company & product name* GF company directory* GF resources* Appendices* Extensive reference list

www.shelleycase.com

SG5

Pocket Dictionary:Acceptability of Foods & Food

Ingredients for the Gluten-Free Diet

* 300+ food and food ingredients

* Description of each item

* Allowed, Not Allowed or ? Check

* 300+ food additives

* Large font for easy reading

* Pocket size, easy-to-carry

www.celiac.ca

131Shelley Case, RD

Other Resources

Organizations- Celiac Disease Foundation www.celiac.org- Gluten Intolerance Group www.gluten.org- Beyond Celiac www.beyondceliac.org- Canadian Celiac Association www.celiac.ca

Tricia Thompson, RD www.glutenfreewatchdog.org

Dr. Steve Plogsted, PharmD, Nationwide Children’s Hospital, Columbus, OH www.glutenfreedrugs.com

132Shelley Case, RD



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