Rising Rates of Celiac

Disease and Gluten

Intolerance:

Fad or Fact?

By Melissa Vondrak

2016-17 MDI Intern

Learning Objectives

To understand the differences between celiac disease and gluten

sensitivities and intolerances

To gain an understanding of the current research behind the increase in

the rise of gluten-free diets

Understand facts about the gluten-free diet that RDs need to be aware of

The Fad Phenomenom

Many celebrities claim to follow a GF diet

Promoted for weight loss, healthier skin,

more energy, etc.

Increased awareness about GF diets

Gluten: Defined

Overall category of storage proteins (prolamins)

Found in certain grains: wheat, rye, & barley

Gives elastic texture to dough

Found in many food products:

Bread

Pasta

Cereal

Gluten and Celiac Disease

Inherited autoimmune disorder

Can occur at any age

Symptoms triggered by consumption of gluten

Body attacks normal tissue in gastrointestinal tract, causing damage

Celiac

Disease

Prevalence: 1-2% of population (1 of every 100)

80-90% remain undiagnosed

Average time before accurate diagnosis: 10-12 years

People of North American and European ancestry

have higher rates of CD

Also common in South America, North Africa, India,

Pakistan, and Middle East

Genetic condition: 1st-degree relatives have a 5-15%

chance of developing CD at any age

Diagnosis and Treatment

Serological Screening Tests

IgA and IgG tissue transglutaminase (tTG)

Gold standard: Small Intestinal Biopsy

Must be on gluten-containing diet

Strict GF diet for life, refer to RD

What if the

test for CD is

negative, but

there are still

symptoms?

Additional conditions to be considered…

Non-Celiac

Gluten

Sensitivity

(NCGS)

1970s: 1st discovered

2009: Evidence rapidly increased, drew attention

0.5-13% of Western population affected

Intestinal and extraintestinal symptoms present

Gluten triggers symptoms, but NOT villous atrophy

Clinical symptoms of NCGS:

Irritable bowel syndrome (IBS)

GI symptoms: bloating, gas, diarrhea, abdominal pain, dyspepsia, etc.

Extraintestinal: fatigue, headache, numbness, mental confusion, anxiety/depression, & fibromyalgia-like symptoms

NCGS

Currently no diagnostic biomarker

Gold standard: double-blind, placebo-controlled (DBPC), cross-over, gluten

challenge

Gluten Challenge:

8 g/day gluten for 1 week (equivalent to 3 slices of bread)

Wash-out period for 1 week

Cross-over to placebo for 1 week

Placebo substance used must be completely GF

Key question to consider:

“What diagnosis should be given to

the majority of symptomatic

patients who feel better on a GF diet

but cannot be formally diagnosed

with NCGS?”

“Melting Pot Hypothesis”

CD on 1 side, Wheat Allergy on the other

Spectrum of other conditions in-between:

Gluten sensitivity

Other components in wheat

Nocebo effect

FODMAP intolerance

Overlapping GI Symptoms

Non-Celiac

Gluten

Sensitivity

(NCGS)

Misdiagnosed celiac disease

1

Early-stage celiac disease

2

FODMAP intolerance

3

Other proteins in wheat

4

Additional Proteins in Wheat

1. Amylase-trypsin inhibitors (ATI)

2. Wheat germ agglutinin

*Note: Commercially available gluten is NOT purified, so the nongluten

proteins (amylase-trypsin inhibitors and wheat germ agglutinin) are NOT

removed for the gluten challenge

FODMAPS

Fermentable Oligosaccharides (fructans and

galactans), disaccharides (e.g., lactose),

monosaccharides (e.g.,fructose) and polyols (e.g.,

mannitol, sorbitol, maltitol, xylitol and some fruits and

vegetables)

Short-chain carbohydrates

Fermentable & poorly digested

May cause bloating, gas & other GI symptoms

Fructans: Barley, Rye, Wheat, Chicory Root, Inulin, Garlic, Onions, Watermelon

Role of RD

GF diet is very complex

20 ppm requirement for food products labeled “gluten-free”

Avoiding cross-contamination is VERY important for a patient with celiac

Food labeling regulations

FDA vs. USDA

Hidden sources of gluten

Various types of wheat

Natural flavors, yeast extract, etc.

Basics of GF Diet

ALL sources of gluten must be avoided

Wheat, barley & rye found in many

various food products

Oats often highly contaminated

Only purity protocol GF oats

recommended

Remember when counseling patients…

It is more than just “avoid these foods”

Food labeling laws – FDA and USDA

Navigating social situations (potlucks, catered events, etc.)

How to avoid cross-contamination when eating out

YOU are a key resource when helping the patient manage a challenging, life-long, gluten-free diet

Summary

Differences between celiac disease and gluten

sensitivities are evident, but research is still emerging

There are no specific biomarkers for NCGS, making it

difficult to diagnose

It is important to get tested for celiac disease before

going on gluten-free diet

The RD plays a vital role in helping a patient manage a

life-long gluten-free diet

Additional

Resources

National Celiac Disease

Foundation

(www.celiac.org)

Gluten Intolerance Group

(www.gluten.org)

Gluten-Free Watchdog

(www.glutenfreewatchdog.org )

References

Case, S., & Case, S. (2016). Gluten free: the definitive resource guide. Altona, Manitoba: Case Nutrition

Consulting, Inc.

Catassi, C., Kryszak, D., Bhatti, B., Sturgeon, C., Helzlsouer, K., Clipp, S. L., . . . Fasano, A. (2010). Natural history

of celiac disease autoimmunity in a USA cohort followed since 1974. Annals of Medicine, 42(7), 530-538.

doi:10.3109/07853890.2010.514285

Fasano, A., & Flaherty, S. (2014). Gluten freedom: the nation's leading expert offers the essential guide to a

healthy, gluten-free lifestyle. Nashville, TN: Wiley General Trade, an imprint of Turner Publishing Company.

Molina-Infante, J., & Carroccio, A. (2017). Suspected Nonceliac Gluten Sensitivity Confirmed in Few Patients

After Gluten Challenge in Double-Blind, Placebo-Controlled Trials. Clinical Gastroenterology and Hepatology,

15(3), 339-348. doi:10.1016/j.cgh.2016.08.007

Screening. (n.d.). Retrieved May 15, 2017, from https://celiac.org/celiac-disease/understanding-celiac-

disease-2/diagnosing-celiac-disease/screening/

Scolapio, J. (2009). Increased Prevalence and Mortality in Undiagnosed Celiac Disease. Yearbook of

Medicine, 2009, 484-485. doi:10.1016/s0084-3873(09)79541-0.

Uhde, M., Ajamian, M., Caio, G., Giorgio, R. D., Indart, A., Green, P. H., . . . Alaedini, A. (2016). Intestinal cell

damage and systemic immune activation in individuals reporting sensitivity to wheat in the absence of

coeliac disease. Gut, 65(12), 1930-1937. doi:10.1136/gutjnl-2016-311964