Hot Topics in Nutrition Hot Topics in Nutrition for School Lunch: Celiacfor School Lunch: Celiac

Carey O’Brien, MS RD LDNCarey O’Brien, MS RD LDN

Celiac DiseaseCeliac Disease

What is it?What is it?

An Auto-Immune diseaseAn Auto-Immune disease There are many different auto-immune There are many different auto-immune

diseases: type 1 DM, Rheumatoid Arthritis, diseases: type 1 DM, Rheumatoid Arthritis, Lupus, Inflammatory Bowel Disease, etc. Lupus, Inflammatory Bowel Disease, etc.

It is a result of an over-active immune It is a result of an over-active immune response to a protein in our foods (Gluten)response to a protein in our foods (Gluten)

What is happening in the body?What is happening in the body?

The body see’s the protein (Gluten) and The body see’s the protein (Gluten) and thinks it is not supposed to be there. thinks it is not supposed to be there.

It “fights” against this protein with an It “fights” against this protein with an antibody (our white blood cells) called antibody (our white blood cells) called Tissue Transglutaminase (tTG).Tissue Transglutaminase (tTG).

This tTG sends a message to the intestine This tTG sends a message to the intestine to keep out the Gluten – which causes to keep out the Gluten – which causes damage to the lining of the intestine. damage to the lining of the intestine.

EndoscopyEndoscopy

Normal Duodenum Duodenal Scalloping

HistologyHistology

Normal Duodenal Mucosa Villous Atrophy

How do you get Celiac?How do you get Celiac?

Three things have to happen together:Three things have to happen together:1.1. You had to have eaten Gluten at some point You had to have eaten Gluten at some point

in your life. in your life.

2.2. You have to carry the gene. You have to carry the gene.

3.3. The Gene has to be turned on (like a light The Gene has to be turned on (like a light switch). But this light switch is broken and switch). But this light switch is broken and once it is turned on – it is never turned off. once it is turned on – it is never turned off. So you never out-grow Celiac. So you never out-grow Celiac.

What are some of the Symptoms?What are some of the Symptoms?

Classic CDClassic CD Abd pain, diarrhea, Abd pain, diarrhea,

constipationconstipation Gas, distentionGas, distention AnorexiaAnorexia Poor wt gain/FTT in Poor wt gain/FTT in

children. children. Unintentional wt loss Unintentional wt loss in adults.in adults.

Irritability/lethargyIrritability/lethargy

22ndnd to MalNutrition to MalNutrition Anemia, fatigueAnemia, fatigue Vitamin defVitamin def Osteopenia Osteopenia Apthous UlcersApthous Ulcers Delayed pubertyDelayed puberty InfertilityInfertility Dental enamel Dental enamel

hypoplasiahypoplasia

How is someone diagnosed?How is someone diagnosed?

All testing must be done while on Gluten All testing must be done while on Gluten containing dietcontaining diet

Bloodwork for antibodies (tTG)Bloodwork for antibodies (tTG) If abnormal, then referral to GI specialistIf abnormal, then referral to GI specialist GI specialist confirms with a scopeGI specialist confirms with a scope

ManagementManagement

C C Consultation with Consultation with skilledskilled dietitian dietitian

E E Education about diseaseEducation about disease

L L Lifelong adherence to GF dietLifelong adherence to GF diet

I I Identification of nutritional deficiencies Identification of nutritional deficiencies

AA Access to a support group Access to a support group

C C Continuous long-term follow-up by Continuous long-term follow-up by multidisciplinary teammultidisciplinary team

Dietitians and Reimbursement Dietitians and Reimbursement IssuesIssues

There is limited or no reimbursement for There is limited or no reimbursement for nutrition counseling for CD by insurance nutrition counseling for CD by insurance companiescompanies

Many patients/families will seek alternative Many patients/families will seek alternative sources (internet, support groups, sources (internet, support groups, family/friends, other health practitioners)…family/friends, other health practitioners)…results in obtaining questionable results in obtaining questionable information.information.

Gluten Free DietGluten Free Diet

Attitudes are contagious!!! Attitudes are contagious!!! Your perceptions of the Your perceptions of the

Gluten free diet are likely to Gluten free diet are likely to become your patients become your patients perceptions. We want to perceptions. We want to give our patients give our patients confidence, independence, confidence, independence, and quality of life that will and quality of life that will ultimately result in better ultimately result in better compliance.compliance.

Label Reading – EliminateLabel Reading – EliminateWHEAT, RYE, BARLEYWHEAT, RYE, BARLEY

BarleyBarley BranBran BulgurBulgur CouscousCouscous DurumDurum EmmerEmmer EinkornEinkorn FarroFarro FarinaFarina

GrahamGraham KamutKamut OrzoOrzo RyeRye SemolinaSemolina Spelt (Dinkel)Spelt (Dinkel) TriticaleTriticale WheatWheat

Label Reading - SafeLabel Reading - Safe

AmaranthAmaranth ArrowrootArrowroot BuckwheatBuckwheat Bean FloursBean Flours CarageenanCarageenan Cassava (Tapioca)Cassava (Tapioca) CornCorn FlaxFlax

MilletMillet Nut FloursNut Flours PotatoPotato QuinoaQuinoa RiceRice Seed FloursSeed Flours SoySoy SorghumSorghum TeffTeff

OatsOats

Currently the inclusion of oats in the GF diet Currently the inclusion of oats in the GF diet remains an area of controversy. remains an area of controversy.

Research regarding the safely of oats for Research regarding the safely of oats for people with celiac disease is still evolvingpeople with celiac disease is still evolving Gluten contamination of oat productsGluten contamination of oat products Oat prolamin (avenin) may trigger it’s own reactionOat prolamin (avenin) may trigger it’s own reaction

Food Allergen Labeling and Food Allergen Labeling and Consumer Protection Act of 2004Consumer Protection Act of 2004

Has two partsHas two parts Part 1 – Effective Jan 2006Part 1 – Effective Jan 2006

Manufacturers must say in plain English if one Manufacturers must say in plain English if one of the 8 most common allergens is in the food. of the 8 most common allergens is in the food.

The Top 8: WHEAT, milk, soy, egg, peanut, The Top 8: WHEAT, milk, soy, egg, peanut, treenut, fish, shellfish. treenut, fish, shellfish.

Wheat is on this list, but rye and barley are Wheat is on this list, but rye and barley are not on this list. So if wheat is in that food as not on this list. So if wheat is in that food as an ingredient, it MUST be listed. an ingredient, it MUST be listed.

Label Reading – Label Reading – QuestionableQuestionable Ingredients Ingredients

Could be WHEATCould be WHEAT Modified Food StarchModified Food Starch FlourFlour Cereal ProductsCereal Products HVP HVP Soy SauceSoy Sauce FlavoringFlavoring

Could be BARLEYCould be BARLEY Malt, Malt Flavoring, Malt, Malt Flavoring,

Malt Extract, Malt Malt Extract, Malt Syrup, Malto-Dextrin, Syrup, Malto-Dextrin, Dextrin, Malt VinegarDextrin, Malt Vinegar

Brown Rice SyrupBrown Rice Syrup

FALCPAFALCPA

Part 2 – Effective Jan 2008Part 2 – Effective Jan 2008 FDA has to come up with a definition for the FDA has to come up with a definition for the

Term: Gluten FreeTerm: Gluten Free Manufacturer’s can choose to label their foods Manufacturer’s can choose to label their foods

as GFas GF

GF Food Guide GF Food Guide Pyramid Pyramid

FruitsFruits – fresh, frozen, canned – fresh, frozen, canned VegetablesVegetables – fresh, frozen, canned – fresh, frozen, canned MeatsMeats – fresh, read labels of processed– fresh, read labels of processed Nuts and BeansNuts and Beans – fresh, canned, dried – fresh, canned, dried DairyDairy – milk, cottage cheese, natural cheese, – milk, cottage cheese, natural cheese,

sour cream, cream cheese. Read labels on sour cream, cream cheese. Read labels on yogurts, ice creams, processed cheese, and yogurts, ice creams, processed cheese, and pudding.pudding.

Food Guide PyramidFood Guide Pyramid

GrainsGrains – – Rice, Corn, Potato in various forms. Rice, Corn, Potato in various forms. Specialty foods required for cereals, breads, pasta, crackers, Specialty foods required for cereals, breads, pasta, crackers,

pizza, pancakes, waffles, cereal bars, communion hosts and pizza, pancakes, waffles, cereal bars, communion hosts and baked goods.baked goods.

Fats/MiscFats/Misc – Oils/Butter, Herbs/Spices. Read labels on – Oils/Butter, Herbs/Spices. Read labels on salad dressings and marinades. GF gravies and cream salad dressings and marinades. GF gravies and cream sauces.sauces.

SweetsSweets – Chocolates like M&M’s, sugar candies, jello, – Chocolates like M&M’s, sugar candies, jello, popsicles, and fruit snacks. (NOT Twizzlers)popsicles, and fruit snacks. (NOT Twizzlers)

Example of MealsExample of Meals Breakfast:Breakfast:

GF cereal with milk, glass of juiceGF cereal with milk, glass of juice Eggs, GF Corn Tortilla, bacon, and milkEggs, GF Corn Tortilla, bacon, and milk

Lunch:Lunch: Rice, unbreaded chicken, cheese, sautéed fajita Rice, unbreaded chicken, cheese, sautéed fajita

vegetables, fruit, milkvegetables, fruit, milk

Snack: Corn chips and salsaSnack: Corn chips and salsa Dinner: Dinner:

Meat, Potato or Rice, veg, milk.Meat, Potato or Rice, veg, milk. MexicanMexican

Snack: Ice CreamSnack: Ice Cream

Cross-contaminationCross-contamination

ToasterToaster Food item containersFood item containers Clean counter tops, cooking Clean counter tops, cooking

equipment, and good equipment, and good handwashing techniquehandwashing technique

Cooking processCooking process

How much gluten is too much??How much gluten is too much??

Hischenhuber and colleagues Hischenhuber and colleagues reviewed a number of studies reviewed a number of studies and concluded that the and concluded that the maximum tolerated daily intake maximum tolerated daily intake of gluten is >10 mg and < 100 of gluten is >10 mg and < 100 mg of gluten.mg of gluten.

This equates to 1/50This equates to 1/50thth to 1/500 to 1/500thth of a slice of bread.of a slice of bread.

CookingCooking

Gluten: our structural protein in foodsGluten: our structural protein in foods Get to know your GF floursGet to know your GF flours

Cooking properties, complementary flours, Cooking properties, complementary flours, best product use.best product use.

Experiment…the kitchen can be a great Experiment…the kitchen can be a great science laboratory!science laboratory!

Web ResourcesWeb Resources

www.pittsburghceliacs.orgwww.pittsburghceliacs.org www.livingwithout.comwww.livingwithout.com www.glutenfreeliving.comwww.glutenfreeliving.com www.glutenfreedrugs.comwww.glutenfreedrugs.com Google: gluten+drugs+shollandGoogle: gluten+drugs+sholland www.gluten.netwww.gluten.net

GIG publications downloaded free of chargeGIG publications downloaded free of charge www.clanthompson.comwww.clanthompson.com

Drugs and gluten alerts/updatesDrugs and gluten alerts/updates

Book ResourcesBook Resources