Living Gluten-free in a Gluten-filled World

Living Gluten-free

in a

Gluten-filled World

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

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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.

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The Diagnosis for CD – 3 Steps

1. Physical examine including blood tests for gluten antibodies (IgA based tests)– EMA anti-endomysial– TTG anti-tissue transglutaminase– DGP Deaminated Gliadin Peptide

2. A small bowel biopsy

3. Implement the gluten-free diet

(process complete when symptoms subside)

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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

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Celiac Disease and Non-Celiac Gluten Sensitivity

Celiac Disease

– autoimmune

– IgA, TTG (or others) positive

– biopsy shows damage

– associated with complications

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

6 Both respond to the gluten-free diet!

CD Prevalence in the U.S.

1: 133 Average healthy people

At Risk Groups:1:56 Related symptoms1:39 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

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

Statistics…..gluten sensitivity

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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 DiseaseSapline 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.

National numbers adding up……..

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.

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

Omaha numbers adding up……..

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.

4,090 1% Celiac Disease (CD)

24,540 6% Gluten Sensitivities (GS)_______________________________________

28,630 7% Total Estimate in Omaha with CD or GS

Census Data 2010 for NE and Omaha, 1,826,341 and 408,958 respectively

*Omaha CSA Chapter has 1700 names; assuming 50% contact CSA the diagnosis rates are likely higher in this area

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 GSUS Census Bureau as of 8/22/11: 312,045,081

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Symptoms…..over 300

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

www.csaceliacs.org13

Symptoms…..

Other– Anemia– Appetite changes– Decreased ability to clot

blood– Decreased fat padding

feet/buttocks/hands– Dehydration

– Delayed puberty– Edema– Electrolyte imbalance– Fatigue– Gluten ataxia

(failure of muscle coordination)

– Infertility/miscarriages

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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

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Other associated conditions….

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

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

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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

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The Diet is the Prescription!

Medical Nutrition Therapy

Dietitians arethe

Nutrition Experts

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Three Step ApproachA Self-Management Guide to the GF Diet

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Step 1 – FoundationBasic self-management

Begin healingMake risk-free choicesChoose naturally gluten-free foodsEliminate wheat, barley, rye, common oats, crosses and derivatives Become knowledgeable Prepared by Jean Guest, PhD, RD, LMNT

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Step 2 – ExpansionIntermediate self-management

Symptoms resolvingEvaluate choicesAddress intolerances and allergiesContinue knowledge process


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Step 3 – MaintenanceAdvanced self-management

Habits for optimal healthEvaluate and update planLiving a full life

Most Common Nutrient Deficiencies

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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

Food Iron (mg) %DV

Beef, chuck, lean only, braised, 3 oz 3.2 20

Turkey, light meat, roasted, 3½ oz 1.6 8

Chicken, breast, roasted, 3 oz 1.1 6

Pork, loin, broiled, 3 oz 0.8 4

Tuna, white, canned in water, 3 oz 0.8 4

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Sources of Non-heme Iron

Food Iron(mg) %DV

Chex Cereal, ¾ c 9 50.00%

Soybeans, mature, boiled, 1 c 8.8 50.00%

Beans, kidney, mature, boiled, 1 c

5.2 25.00%

Molasses, blackstrap, 1 T 3.5 20.00%

Spinach, boiled, drained, ½ c 1.9 10.00%


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Sources of B-12


Food B-12 (mcg) %DV

Trout, rainbow, farmed, cooked, 3 oz

5.4 90.00%

Salmon, sockeye, cooked, 3 oz 4.9 80.00%

Beef, top sirloin, broiled, 3 oz 2.4 40.00%

Breakfast Cereals, fortified with 25% B12 (Chex Cereal, 3/4c)

1.5 25.00%

Yogurt, plain, 1 cup 1.4 25.00%

Milk, 1 cup 0.9 15.00%

Egg, large, 1 whole 0.6 10.00%

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Sources of Folate/Folic Acid


Food Micrograms(μg) %DV

Chex Cereal, fortified with 50% of DV, 200 50.00%

Spinach, frozen, cooked, boiled, ½ c 100 25.00%

Great Northern beans, boiled, ½ c 90 25.00%

Asparagus, boiled, 4 spears 85 20.00%

Rice, white, long-grain, parboiled, enriched, cooked, ½ c

65 15.00%

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Food Sources of Calcium


Food Calcium(mg) %DV

Yogurt, plain, low fat, 8 oz 415 42.00%

Sardines, canned in oil, with bones, 3 oz 324 32.00%

Cheddar cheese, 1.5 oz 306 31.00%

Milk, nonfat, 8 oz 302 30.00%

Mozzarella, part skim, 1.5 oz 275 28.00%

Orange juice, calcium-fortified, 6 oz 200-260 20-26%

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Food Sources of Vitamin D


Food Vit D (IU's) %DV

Cod liver oil,1T 1360 340.00%

Salmon, sockeye, cooked, 3oz 794 199.00%

Tuna fish, canned in water, drained, 3 oz 154 39.00%

Milk, nonfat, reduced fat, and whole, vitamin D-fortified, 1 c

115-124 29-31.00%

Orange juice fortified with vitamin D, 1 c(check product labels, as amount of added vitamin D varies)

100 25.00%

Yogurt, fortified vitamin D, 6 oz (more heavily fortified yogurts provide more of the DV)

80 20.00%

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Non-Food Sources of Vitamin D

Be sensible!! Don't burn!

5 - 10 minutes per day

30 minutes = 20,000 IU's

VitaminDHealth.org

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Food Sources of Fiber

Food Fiber (g)

Wild Rice, ½ c 4.5

Flax Seed, 2 T 6

Raspberries, ½ c 4

Baked Beans, canned, plain, ½ c 5.2

Sweet potato, cooked, no skin, 1 medium 3.9

Almonds, 1 oz 3.3

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/.30

Supplement Savvy

GF Multivitamin GF B-Complex VitaminGF Vitamin DGF Calcium

Talk with your health care team!31

Where is gluten found?...

wheatbarley ryeoats (unless gf)(WBRO)

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Additional sources of gluten….

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

A gluten-free diet means no:

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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-free34

Preparing for the grocery store

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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

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How to know if something is gluten-free?

CSA Recognition Seal< 5 ppm

GIG Certification< 10 ppm

NFCA Certification<10 ppm

Health Canada dictates - 20 ppm is guide37

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

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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.

8 Allergens

EggsFishMilkPeanuts

ShellfishSoybeansTree nutsWheat

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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.

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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

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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

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Label Reading Savvy Ex 2

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Frozen Turkey

Ingredients: Turkey, Water, Salt, Modified Food Starch, Sodium Phosphates, Natural Flavorings

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

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.

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Hidden Sources of Gluten

The Three C’s – Content, Contact, ContaminationContent - Foods

Breading Brewer’s Yeast Broth Brown rice syrup Casseroles Croutons Gravies

Foods injected with broth Modified food starch Sauces Soy sauce Seasonings Processed foods Cold cuts, deli foods, pre-

cooked foods, frozen foods

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Hidden Sources of Gluten

The Three C’s – Content, Contact, Contamination

• Manufacturing• Flour dust in air• Flour on conveyor

belts• School

• Play dough• Paints• Crayons

Content and Contact – Other Items

• Personal Care Items• Lipstick, make

up• Lotions• Medications

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Tips to avoiding cross-contact

Separate area and items needed to avoid cross-contact:

StrainersUtensils, Parchment PaperToaster OvenDesignated Prep Area or Station

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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

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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)

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Gluten-Free Sources of Fiber

Indian wheat grass (Montina)MilletRice branBrown rice flourSoy flourTeffQuinoaPea Hull Fiber

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Discover New Foods

Amaranth: used in ancient civilizations, robust, nutty flavor

Buckwheat: actually is a fruit and a relative of rhubarb, nutty flavor

Flax: size of sesame seed, grind to improve nutrient absorption

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Discover New Foods

Millet: closely related to corn, nutty flavor Indian rice grass: sweet, nutty, almost

wheat like flavorQuinoa: strong flavor, combine with other

flours or foodsSorghum: nutty flavor

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Discover New Foods

Teff: grass, mild molasses-like flavor, more nutritious than common grains

Wild rice: is not a member of the rice family, nut-like flavor

Reference: Case, Shelley, Gluten-Free Diet, April 2006, www.glutenfreediet.ca

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Kitchen Pantry Smarts!Keep gf items in separate container

Keep gf items above other items

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Resources –Support Groups

Celiac Sprue Association www.csaceliacs.org

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What does a support group provide?

Resources for daily living that are based on science and research

Life long friendships to journey the path of living gluten-free

National support from headquartersAs RD, need to help groups “filter”

information

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ADA Resources

Evidence Analysis Library (EAL) 2009– Evidence-based Nutrition

Practice Guidelines for Celiac Disease– www.adaevidencelibrary.com

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ADA Resources

Celiac Disease Toolkit based on the EAL data,visit www.eatright.org for more information

DIGID-Dietitians in Gluten Intolerance Diseases (a sub- unit of the Medical Nutrition Practice Group) www.mnpg.org

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CSA Resources

CSA Web-site: www.csaceliacs.org– Toll Free: 877-272-4272– Local Support Group Information– Three Step Diet Approach (Self-Mngt Approach)

– Counting Gluten-Free Carbohydrate Guide!!!Just download, its free!

– Fact Sheets on Common Nutrient Deficiencies

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CSA Tools CSA Gluten-Free Product Listing

Available: - CD - Spiral Bound Book

- iPad or iPhone App “GlutenFreeMe” http://itunes.apple.com/us/app/glutenfreeme

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Other resources

Grocery Store Gluten-Free Listings– Hy-Vee Example:

http://www.hy-vee.com/meal-solutions/special-diets/default.aspx

NIH – Teaching Materials– http://www.celiac.nih.gov/Materials.aspx

Gluten Free Drugs:– www.glutenfreedrugs.com

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Gluten-free living!

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Activity

Break into 6 groups Plan gluten-free options for one of the following:

- children’s birthday party

- evening catered evening event at Joslyn

- bed and breakfast

- hospital – mother just delivered baby

- bar and grill

- assisted living center

Thank you!

Shelly Asplin, MA, RD, LMNT

Celiac Sprue Association

[email protected] Box 31700 Omaha, NE 68131-0700

Toll Free: 877-CSA-4CSA · Fax: 402-643-4108

www.csaceliacs.org

www.facebook.com/csaceliacs

www.twitter.com/csaceliacs

Documents

Living Gluten-free in a Gluten-filled World