gluten: fads vs. facts
DESCRIPTION
Vandna Jerath, MD discusses gluten: fads vs. facts and the impact on your health for the Women's Health & Wellness Expo for Parker Adventist Hospital at the Parker PACE Center. Learn about gluten, celiac disease, gluten sensitivity, a gluten free diet, and evolving gastroenterology (GI) research.TRANSCRIPT
Vandna Jerath, MD, FACOG
Women’s Health & Wellness Expo | PACE Center | Parker Adventist Hospital
drjerath.com optimawomenshealthcare.com
October 3, 2014
FACOG – Board-Certified
Private practice – 16 years
Full scope obstetrics & gynecology
Enjoy education and community outreach
Disclosures – no affiliations
Healthcare social media expert
drjerath.com
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
General Ob/Gyn Services
Women’s health resource/expert
Female empowerment ◦ Be educated Be engaged Be empowered
Spa-like setting
Individualized, personalized, and compassionate care
optimawomenshealthcare.com
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
To understand what gluten is and the impact it has on health.
To learn about celiac disease including prevalence, signs/symptoms, diagnosis, and management.
To understand the evolving spectrum of gastroenterological conditions, particularly regarding gluten and gluten sensitivity.
To understand the dietary restrictions of a gluten free diet.
To be able to sort out the health vs. hype regarding gluten.
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Jimmy Kimmel video ◦ http://www.youtube.com/watch?v=AdJFE1sp4Fw
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
What is all the fuss? ◦ Less people eating gluten ◦ Revenue producing for the food industry ◦ Potentially life threatening for people with celiac disease
May cause GI symptoms ◦ Allergy vs. intolerance
Diet fad Why?
◦ GMO crops?
Possible overdiagnosis and overtreatment Media stories
◦ NY Times blog article – 9/29/2014 ◦ Celiac Disease, a Common, but Elusive, Diagnosis ◦ http://well.blogs.nytimes.com/2014/09/29/celiac-disease-diagnosis-
gluten/?_php=true&_type=blogs&_r=0
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Protein found in grains ◦ Wheat, barley, and rye ◦ Gliadin peptides
Found in common foods ◦ Cereal ◦ Bread ◦ Baked goods ◦ Pasta ◦ Battered and possibly fried foods ◦ Malt ◦ Sauces, marinades, salad dressings, soy sauce, gravy ◦ May be hidden in processed foods ◦ Preservatives ◦ Beer
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Natural, plain, or unprocessed foods ◦ Meats/Poultry/Fish
◦ Fruits
◦ Vegetables
◦ Beans
◦ Dairy
◦ Nuts
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: M. Dennis, S. Case, 2008 as appeared in Practical Gastroenterology, April 2004 and BIDMC presentation by Daniel Leffler, MD, MS and Melinda Dennis, MS, RD, LDN.
Safe grains, starches, & flours ◦ Rice ◦ Corn ◦ Soybeans ◦ Tapioca ◦ Potato ◦ Quinoa ◦ Millet ◦ Flax ◦ Arrowroot ◦ Amaranth ◦ Buckwheat ◦ Sorghum ◦ Millet ◦ Teff ◦ Nut flours (almond, pecan) ◦ Seed flours (sesame) ◦ Legume flours(garbanzo, lentil) ◦ Bean flours
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: M. Dennis, S. Case, 2008 as appeared in Practical Gastroenterology, April 2004 and BIDMC presentation by Daniel Leffler, MD, MS and Melinda Dennis, MS, RD, LDN.
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: Thompson T. Celiac Disease Nutrition Guide, 2nd ed. Chicago: American Dietetic Association; 2006.
Allowed Foods
amaranth arrowroot buckwheat cassava corn flax Indian rice grass Job's tears
legumes millet nuts potatoes quinoa rice sago
seeds sorghum soy tapioca teff wild rice yucca
Foods To Avoid
•wheat including einkorn, emmer, spelt, kamut •wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein
barley rye triticale (a cross between wheat and rye)
Other Wheat Products
bromated flour durum flour enriched flour farina
graham flour phosphated flour plain flour
self-rising flour semolina white flour
Processed Foods that May Contain Wheat, Barley, or Rye*
bouillon cubes brown rice syrup candy chips/potato chips cold cuts, hot dogs, salami, sausage communion wafers
French fries gravy imitation fish matzo rice mixes sauces
seasoned tortilla chips self-basting turkey soups soy sauce vegetables in sauce
The Gluten-free Diet: Some Examples In 2006, the American Dietetic Association updated its recommendations for a gluten-free diet. The following chart is based on the 2006 recommendations. This list is not complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten.
Digestive disease that damages small intestine ◦ Damaged villi of the small intestine ◦ Malabsorption of nutrients ◦ Celiac disease (CD), Celiac sprue, nontropical sprue, gluten-sensitive enteropathy
Autoimmune reaction Intolerance to gluten
◦ How does it start? ◦ Surgery, infection, cereal < 3mo age, hereditary?
Prevalence 1 in 100 Women > Men
◦ 2/3 of current diagnosis are female
More common in Caucasians Genetic (5-10% first degree relative) May take 10 years or more for diagnosis
◦ Average age of diagnosis is 50 ◦ Confusing symptoms
17% of Americans don’t know they have the disease Lifelong gluten free diet is the only treatment
◦ Less than 20ppm
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006; 131:1977-1980. Source: Celiac Disease. NIH Publication No. 08-4269. September 2008.
Husby, S. & Murray, J. A. (2014) Diagnosing coeliac disease and the potential for serological markers Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2014.162
Abdominal bloating Abdominal pain Chronic diarrhea Vomiting Constipation Stool abnormalities
◦ Pale, foul-smelling, fatty
Weight loss Irritability Malabsorption Fatigue Joint pain Muscle pain Osteopenia/Osteoporosis Iron-deficiency anemia Tingling in hands/feet Headaches
Abnormal menses ◦ Infertility ◦ Recurrent miscarriage
Canker sores Skin rash - itchy
◦ Dermatitis herpetiformis ◦ Dapsone treatment
Cognitive impairment – brain fog Ataxia Automimmune diseases
◦ Thyroid disease ◦ Rheumatoid arthritis ◦ Type 1 diabetes ◦ Sjogren’s syndrome ◦ Addison’s disease ◦ SLE (lupus)
Non Hodgkin’s Lymphoma
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006; 131:1977-1980. Source: Celiac Disease. NIH Publication No. 08-4269. September 2008.
Must be on a gluten diet for testing Blood tests
◦ IgA tissue trans-glutaminase antibodies (tTG) Most efficient single serologic test
◦ IgA/IgG deaminated gliadin peptide antibodies (DGP)
Genetic testing ◦ Human leukocyte antigen (HLA) haplotypes ◦ DNA PCR ◦ HLA DQ2 (95%)/DQ8 (5%) No celiac if these are negative
Intestinal biopsies ◦ Multiple biopsies ◦ Histological testing for villous atrophy ◦ Gold standard for diagnosis
Skin biopsies Equivocal test results can occur
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006; 131:1977-1980
Consultation with a skilled dietitian
Education about the disease
Lifelong adherence to a gluten free diet
Identification and treatment of nutritional deficiencies
Access to an advocacy group
Continuous long-term follow-up by a multidisciplinary team
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: NIH Consensus Development Conference on Celiac Disease.
Is there a spectrum of disease?
Non-celiac gluten sensitivity (NCGS) ◦ First described in 1980’s now “re-discovered”
GI symptoms responsive to a gluten free diet ◦ May be able to titrate their gluten exposure to avoid symptoms
Prevalence unclear ◦ Many people self-diagnose and start a gluten free diet without
medical consultation (not recommended)
◦ .5-6% based upon different studies
◦ More common in females
Transitory or permanent?
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: Fasano A, et al. Non-celiac gluten sensitivity: the new frontier of gluten related disorders. Nutrients. Oct 2013; 5(10): 3839-3853
Diagnosis ◦ Difficult to distinguish from irritable bowel syndrome (IBS) or wheat allergy (WA) ◦ Lack of biomarkers for diagnosis
First generation IgG AGA – 7.7%
HLA DQ2/DQ8 – 50%
◦ Different histological changes on intestinal biopsy
Present ◦ Younger age (case reports in children) ◦ Lack autoimmune or family history ◦ Constipation
Less likely to be at risk ◦ Malabsorption ◦ Severe nutrient deficiencies ◦ Lymphoma ◦ No major complication if untreated
Evolving spectrum ◦ Some more like celiac disease ◦ Some more like food allergy ◦ Is GMO wheat contributing? ◦ Possible relationship to autism and schizophrenia ◦ May be related to wheat amylase-trypsin inhibitors ◦ May be related to low-fermentable, poorly absorbed, short chain carbohydrates
Reduced FODMAPs (fermentable oligo-, di-, and mono-saccharides and polyols) diet
Fructans, galactans, fructose, and polyols
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: Fasano A, et al. Non-celiac gluten sensitivity: the new frontier of gluten related disorders. Nutrients. Oct 2013; 5(10): 3839-3853.
Nonceliac enteropathy (NCE) ◦ Can mimic celiac disease
◦ May cause villous atrophy
◦ Can respond to a gluten free diet
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Challenges ◦ Cross-contamination ◦ Hidden ingredients ◦ Preservatives
Wheat free is not gluten free Not necessarily low fat or for weight loss Avoid ◦ Wheat ◦ Malt ◦ Modified food starch ◦ Dextrin ◦ Hydrolyzed wheat protein
DO NOT START w/o confirming or ruling out celiac disease
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Fads ◦ It is a good weight loss diet. ◦ Will make you “sick” or “fat”. ◦ GI symptoms will definitely occur. ◦ Healthy for you. ◦ Everyone is doing it. ◦ Ok to start a gluten free diet without a diagnosis.
Facts ◦ People with celiac disease have a permanent lifelong intolerance and cannot
eat gluten. ◦ May cause an autoimmune response with GI symptoms. ◦ Some people may have an allergy or sensitivity. ◦ Gluten free diet may improve sensitivity symptoms. ◦ Medical information and evidence is evolving. ◦ Do not start a gluten free diet without a medical diagnosis or consultation.
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Americanceliac.org Celiac.com Celiac.org Celiaccentral.org Csaceliacs.org Eatright.org Gluten.net Glutenfreedrugs.com Healthyvilli.org NIH –
http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/ Reallifewithceliacdisease.com
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Facebook ◦ Facebook.com/drjerath ◦ Facebook.com/optimawhc
Twitter ◦ Twitter.com/drjerath ◦ Twitter.com/optimawhc
YouTube ◦ Youtube.com/doctorjerath
Linked In ◦ Linkedin.com/in/drjerath ◦ Linkedin.com/company/optima-women's-healthcare
Google + ◦ https://plus.google.com/101535200386086719829 ◦ https://plus.google.com/117179751484494619443
Pinterest ◦ Pinterest.com/drjerath ◦ Pinterest.com/optimawhc
Blog ◦ Drjerath.com
Website ◦ Optimawomenshealthcare.com
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Vandna Jerath, MD Optima Women’s Healthcare Sierra Medical Office Building Parker Adventist Hospital Campus 9399 Crown Crest Blvd, Suite 450 Parker, CO 80138 303.805.1807 P | 303.595.5390 F optimawomenshealthcare.com drjerath.com Email - [email protected] Slides – http://slideshare.net/VandnaJerathMD
Women’s Health & Wellness Expo | PACE Center | 10/3/2014