4/7/2013 1 Cynthia Kupper, RD Gluten Intolerance Group of NA [email protected]Approaches to DX of CD and NCGS Symptoms and lab values indicative of CD or NCGS Implementation of: ◦ a healthful and safe GFD - food choices & meal planning potential nutrient deficiencies ◦ cross contamination issues ◦ label update ◦ GF product update The Oslo definitions for coeliac disease and related terms The Oslo definitions for coeliac disease and related terms The Oslo definitions for coeliac disease and related terms The Oslo definitions for coeliac disease and related terms Gut2013;62:43-52 doi:10.1136/gutjnl-2011-301346 Original publication Jan 2012 Celiac disease Asymptomatic CD Classical CD Pediatric Classical CD Non-classical Potential CD Refractory CD Subclinical CD Symptomatic CD CD autoimmunity Genetically at risk of CD Dermatitis Herpetiformis Gluten Gluten Ataxia Non-celiac gluten sensitivity Gliadin-specific antibodies
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Kupper - Gluten update · Classical CD Pediatric Classical CD Non-classical Potential CD Refractory CD Subclinical CD ... Many are asymptomatic until diagnosed with another condition
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� Symptoms and lab values indicative of CD or NCGS
� Implementation of:◦ a healthful and safe GFD - food choices & meal planning
� potential nutrient deficiencies
◦ cross contamination issues
◦ label update
◦ GF product update
The Oslo definitions for coeliac disease and related termsThe Oslo definitions for coeliac disease and related termsThe Oslo definitions for coeliac disease and related termsThe Oslo definitions for coeliac disease and related terms
Gut2013;62:43-52 doi:10.1136/gutjnl-2011-301346Original publication Jan 2012
� Celiac disease Celiac disease Celiac disease Celiac disease (CD) - chronic small intestinal immune-mediated enteropathy from exposure to dietary gluten in genetically predisposed people.
◦ triggered by the ingestion of gluten
◦ variable degree of intestinal damage
◦ enteropathy reverse on a GFD
� NonNonNonNon----classicalclassicalclassicalclassical – w/o signs and symptoms of malabsorption.
� SymptomaticSymptomaticSymptomaticSymptomatic - clinically evident GI and/or extra-intestinal symptoms attributable to gluten intake.
� RefractoryRefractoryRefractoryRefractory (RCD) -persistent or recurrent malabsorptive symptoms and signs with villous atrophy (VA) despite a strict GFD for more than 12>months. Classified as type l or ll
CDCDCDCD� Asymptomatic Asymptomatic Asymptomatic Asymptomatic - not accompanied by symptoms
� Classical Classical Classical Classical – Adults: w/ signs and symptoms of Diarrhea, malabsorption, steatorrhea, weight loss or growth failure is required.
� Pediatric - failure to thrive, diarrhea, muscle wasting, poor appetite & abdominal distension. May include signs of emotional distress (‘change of mood’) and lethargy.
� Potential CD Potential CD Potential CD Potential CD - persons w/ a nl small intestinal mucosa & at increased risk of developing CD as indicated by positive CD serology
� GlutenGlutenGlutenGluten –water insoluble proteins from wheat, rye, and barley (but not oats)◦ broad group of prolamins(gliadin and glutenins)
� CD autoimmunity CD autoimmunity CD autoimmunity CD autoimmunity -increased TTG or EMA on at least two occasions when status of the biopsy is not known. ◦ biopsy is positive = CD◦ biopsy is negative = potential CD
� Genetically at risk of Genetically at risk of Genetically at risk of Genetically at risk of CD CD CD CD - family members of persons with CD that test positive for HLA DQ2 and/or DQ8◦ Risk varies between 2-20%� Degree family member � # copies of HLA-DQ2 genes
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� GlutenGlutenGlutenGluten----related related related related disorders disorders disorders disorders - all conditions related to gluten◦ CD
◦ NCGS
◦ DH
◦ Gluten Ataxia
� NCGSNCGSNCGSNCGS - a variety of immunological, morphological or symptomatic manifestations precipitated by gluten in absence of CD
An estimated 3 million people (1 in 133 people)have Celiac Disease in the US
An estimated 17 million have Non Celiac Gluten Sensitivity
(6 to 7 times higher than CD)
(15% of US population is estimated to have IBS)
Celiac Disease is the most common under-diagnosed GI disorder
� Diagnosis takes an average of 4.5 years
� Average age at diagnosis: 4th or 5th decade of life
� Risk of developing other autoimmune conditions increases
with delayed diagnosis
� Many are asymptomatic until diagnosed with another condition
� Estimated 95% of CD cases are undiagnosed
Auto-ImmuneNot auto-immune or
allergy. Possibly
Immune – mediated.
Not yet clearly defined.
Celiac Disease
Non Celiac
Gluten Sensitivity
Reaction to Glutento Glutento Glutento Gluten
Wheat AllergyDermatitis
Herpetiformis
Refractory
Sprue
Allergy
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� Gluten is resistant to the digestive and pancreatic enzymes which usually break down proteins into small amino acid molecules for easy absorption.
� Remaining long peptide chains are harmful to those with gluten intolerances and destroy the lining of the small intestine in Celiac Disease and Dermatitis Herpetiformis.
� In Non Celiac Gluten Sensitivity, intestinal lining is not destroyed, but some intestinal inflammation/reaction may occur.
Test for antibody against the gliadin portion of the gluten protein. Not sensitive enough in adults to be used as a primary diagnostic; used for very young children. Indicates reaction to gluten.
Test for antibodies which attack the tissue transglutaminase enzyme responsible for repairing damage to the intestinal tract. Very specific for celiac disease.
Total IgA Total IgA Total IgA Total IgA Test to determine IgA deficiency. If IgA deficient,diagnosis dependent on IgG results.
Genetic MarkersGenetic MarkersGenetic MarkersGenetic Markers Two genes associated with celiac disease: HLA-DQ2 and HLA-DQ8, indicate genetic susceptibility. Negative result rules out CD for life; positive results not conclusive.
Small Intestine BiopsySmall Intestine BiopsySmall Intestine BiopsySmall Intestine Biopsy Tissue biopsy of the small intestine to determine villous atrophy. Very specific for celiac disease. Final required step to diagnose CD.
AllergenAllergenAllergenAllergen----specific specific specific specific Measures the amount of allergen-specificAntibody (IgE)Antibody (IgE)Antibody (IgE)Antibody (IgE) immunoglobulin E in the blood. Detects
allergy to a particular substance such as wheat. Not relevant for celiac disease.
Skin Skin Skin Skin BiopsyBiopsyBiopsyBiopsy Tissue biopsy on clear area of skin around the blister for evaluating IgA deposits to determine diagnosis of Dermatitis Herpetiformis.
Diagnosing Non Celiac Gluten Sensitivity
• Antibody tests and intestinal biopsy to rule out celiac disease
• Negative wheat allergy tests
• Gluten-Free diet results in improvement
• Return of gluten to diet causes return of symptoms
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CELIAC DISEASENON CELIAC GLUTEN
SENSITIVITYWHEAT ALLERGY
•AGA-IgA/IgG•Elimination Diet•Rule out other conditions
•RAST (IgE, IgG, IgM)•Placebo challenge (double-blind)•Skin prick test
CELIAC DISEASECELIAC DISEASECELIAC DISEASECELIAC DISEASENON CELIAC NON CELIAC NON CELIAC NON CELIAC NON CELIAC NON CELIAC NON CELIAC NON CELIAC GLUTEN GLUTEN GLUTEN GLUTEN
� Fresh produce: naturally gluten-free and very nutritious
� Ethnic cuisines, dishes and flavors: many Mexican, Indian and Asian foods are naturally gluten- free: corn tortillas, salsas, lentil and vegetable curries, stir fries (confirm use of GF soy sauce)
� Explore new grains and flours
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PastaPastaPastaPasta Brown rice pasta, white rice, or bean thread noodles; (other gluten-free pastas, e.g. corn/quinoa)
•Use pourable/squeezable condiments to avoid risk of “double dipping” or have dedicated condiments for “GF” use only
•Store GF foods on separate refrigerator and pantry shelves
� Few medications contain gluten, but it can exist as a filler. ◦ Exception may be herbal supplements
� No labeling requirements for medications. Source of ingredients must be verified.
� Good resource: www.glutenfreedrugs.com
� Skincare products: Gluten is not absorbed through the skin. However, avoid gluten-containing shampoo and lotion for kids, since some may unknowingly be ingested.