Objectives Diabetes Celiac Disease · What is Celiac Disease? • Also known as coeliac disease and celiac sprue, gluten‐sensitive enteropathy, and non‐tropical sprue • CD is
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• Also known as coeliac disease and celiac sprue, gluten‐sensitive enteropathy, and non‐tropical sprue
• CD is an immune‐mediated enteropathy triggered in genetically susceptible individuals
History of Celiac Disease
• 1888 ‐ First described by Samuel Gee, MD
• Late 1940’s – during WW II – Willem Karl Dicke, MD noticed that his patients improved during the war but relapsed at during the restoration after the war
• 1949 – Dr. Paulley – 1st small bowel biopsy ‐ villous atrophy and crypt hyperplasia
• 1973‐ first report in Western Ireland that the prevalence was 1 in every 300 people BMJ 1973;3:703‐705
• 1970‐1980’s – a lot of research went into developing screening test– Anti‐gliadin antibodies (AGA)– IgA endomysial antibodies (EMA)
• 1997 – tTG – tissue transglutaminase
Celiac Disease in London in 1938
Celiac Disease in the USA 80‐90’s
Celiac Disease
• Primary trigger is gluten (gliadin) containing grains wheat, rye and barley
• Sometimes the disease is triggered or becomes active for the first time– Surgery
– Pregnancy
– Childbirth
– Viral infection
– Severe emotional stress
GeneticsType 1 diabetes:
• HLA‐DR4 and DR3 are associated with T1D
– 30‐50% of patients being heterozygotes
• HLA‐DQ2 and DQ8 locus most important in determinant of diabetes susceptibility
– ~90% of individuals with T1D have either
• Highest risk for T1D is DR3‐DQ2 and DR4‐DQ8
CamarcaME, et al. Celiac disease in type 1 diabetes mellitus. Italian Journal of Pediatrics 2012, 38:10
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Celiac disease:
• HLA‐DQ2 and HLA‐DQ8 facilitate the initiation of the autoimmune response to gluten
• 30% ‐ 40% of the U.S. population have HLA‐DQ2 and HLA‐DQ8
• HLA association
• HLA‐DQ2 is found in 95% patients
• HLA‐DQ8 in the remainder 5%
• Family members who test positive HLA‐DQ2 and HLA‐DQ8 have risk of 2‐20% depending on the degree of the relative with CD
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Prevalence of Celiac Disease in the US
• In not at risk people: 1 in 133
– Adults 1:105
– Children 1:320
• In people with related symptoms: 1 in 56
• In people with first‐degree relatives (parent, child, sibling)who are celiac: 1 in 22
• In people with second‐degree relatives (aunt, uncle, cousin) who are celiac: 1 in 39
• Estimated prevalence for African‐, Hispanic‐, Asian‐Americans: 1 in 236
A multi‐center study on sero‐prevalence of celiac disease in the United States among both at risk and not at risk groups. Fasano et.al., Archives of Internal Medicine. February 2003
Prevalence of Celiac Disease in the US
• Estimated to be prevalent in 1% of the population
• CD is estimated to affect >3 million Americans – 97% undiagnosed
• 2014 Estimated Census – MA census was 6,745,408
• ~67,454 people in MA have CD
– Boston was 655,884– ~6,559 people in Boston have CD
• New England Celiac Organization (NECO) membership ~1000
• 6 ‐ 16% of children & adults with Type 1 diabetes also have celiac disease
http://censusviewer.com/city/MA/Boston
Rubio‐Tapia A et al. Predictors of family risk for CD: a population‐based study. Clin Gastroenterol Hepatol2008:6:983‐7
CELIACPRESENTATION
classicceliac disease
symptomaticceliac disease
asymptomaticceliac disease
refractoryceliac disease
potentialceliac disease
Prevalence of Celiac Disease in World
Abadie V, Sollid LM, Barreiro LB, Jabri B. Integration of genetic and immunological insights into a model of celiac disease pathogenesis. Annu Rev Immunol 2011;29:493–525
Normal vs. Damaged Villi
High Resolution Endoscopy Disorders Associated with Celiac Disease
• Other– Anemia– Osteoporosis– Turner Syndrome– Down Syndrome
Alaedini A, Green PHR, Narrative review: celiac disease: understanding a complex autoimmune disorder. Ann Intern Med;142:289‐298.
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Recommendations to Screen The American Diabetes Association recommends screening select patients based on symptoms and treating patients with biopsy‐confirmed celiac disease with the gluten‐free diet. Executive summary: standards of medical care in diabetes—2011. Diabetes Care. 2011;34(suppl 1):S4‐10.
The International Society for Pediatric and Adolescent Diabetes recommends treating patients with symptomatic celiac disease and comments on the controversy and uncertainty over treating asymptomatic celiac disease in type 1 diabetes. Kordonouri O, Maguire AM, Knip M, et al. ISPAD Clinical Practice Consensus Guidelines 2006‐2007. Other complications and associated conditions. Pediatr Diabetes. 2007;8(3):171‐176.
The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition recommends routine screening of all children with type 1 diabetes but notes that the treatment may not have an effect on glycemic control.Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005;40(1):1‐19.
The National Institute of Health Consensus Conference on celiac disease recommends screening of type 1 diabetes patients with symptoms and treating biopsy proven celiac disease.NIH Consensus Development Conference on Celiac Disease. NIH Consens State Sci Statements. 2004;21(1):1‐23.
The Canadian Diabetes Association recommends screening patients with symptoms and notes that for those with no symptoms, treatment is controversial.Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian J Diabetes. 2008;32(suppl 1):22‐35.
Recommendations to Screen The American Diabetes Association recommends screening select patients based on symptoms and treating patients with biopsy‐confirmed celiac disease with the gluten‐free diet. Executive summary: standards of medical care in diabetes—2011. Diabetes Care. 2011;34(suppl 1):S4‐10.
The International Society for Pediatric and Adolescent Diabetes recommends treating patients with symptomatic celiac disease and comments on the controversy and uncertainty over treating asymptomatic celiac disease in type 1 diabetes. Kordonouri O, Maguire AM, Knip M, et al. ISPAD Clinical Practice Consensus Guidelines 2006‐2007. Other complications and associated conditions. Pediatr Diabetes. 2007;8(3):171‐176.
The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition recommends routine screening of all children with type 1 diabetes but notes that the treatment may not have an effect on glycemic control.Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005;40(1):1‐19.
The National Institute of Health Consensus Conference on celiac disease recommends screening of type 1 diabetes patients with symptoms and treating biopsy proven celiac disease.NIH Consensus Development Conference on Celiac Disease. NIH Consensus State Sci Statements. 2004;21(1):1‐23.
The Canadian Diabetes Association recommends screening patients with symptoms and notes that for those with no symptoms, treatment is controversial.Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian J Diabetes. 2008;32(suppl 1):22‐35.
• Foul smelling stools• Inability to concentrate• Infertility • Irritability • Iron deficiency• Muscle cramps• Osteopenia • Osteoporosis• Short stature• Sleep disturbance• Weakness• Weight loss• Vomiting
N Engl J Med 2012:367:2419‐26.
Celiac Disease Classification
• Classical CD – presents with signs & symptoms of malabsorption, weight loss, or growth failure is required.
• Non‐classical CD – presents without signs & symptoms of malabsorption (constipation or abdominal pain)
• Subclinical CD – below the threshold for clinical detection without signs or symptoms sufficient trigger CD testing in routine practice.
• Symptomatic CD – is characterized by clinically evident GI and/or extraintestinal symptoms attributed to gluten intake.
• Refractory CD – is persistent or recurrent malabsorptivesymptoms & signs with villous atrophy despite a strict GFD for > 12 months.
Ludvigsson JF et al. The Oslo definitions for coeliac disease and related terms. Gut. 2013;62:42‐52.
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Algorithm for diagnosing celiac disease
Alaedini A, Green PHR, Narrative review: celiac disease: understanding a complex autoimmune disorder. Ann Intern Med;142:289‐298.
Screening for Celiac Disease
• IgA Deficiency • 0.2% of the population
• 2‐3% of people with CD
• The antibodies (TTG & DGPs) are dependent on the ingestion of gluten. – 6‐12 months on a strict GFD, 80% will test negative
– 5 years, more than 90% will test negative
• The “Gold Standard” for confirming the diagnosis is a small bowel biopsy
Rashtak S et al. Comparative usefulness of deamidated gliadin antibodies in the diagnosis of celiac disease. Clin Gastroenterol Hepatol 2008;6:426‐32Zanini B et al. Five year time course of CD serology during GFD: results of a community based “CD‐Watch program. Dig Liver Dis 2010;42:865‐70.
Dermatitis Herpetiformis (DH)• DH is a cutaneous manifestation of small
intestine immune‐mediated enteropathy precipitated by gluten. It is characterised by hepetiform clusters of the pruritic urticated papules and vesicles on the skin and IgA deposits in the dermal.
• Usually have milder enteropathy• 47% of people can stop medication therapy
• Medications often used to help with the rash (Dapsone)
• Occurs most commonly in individuals of European origin
Ludvigsson JF et al. The Oslo definitions for coeliac disease and related terms. Gut. 2013;62:42‐5Salmi TT et al. Prevalence and incidence of DH: a 40‐year prospective study from Finland. Brit J Dermatol 2011. 165:354‐359.
Non Celiac Gluten Sensitivity (NCGS)
• Prevalence unknown in general population
• Characterized by symptoms soon after eating gluten, disappear after withdrawal of gluten and reoccur following a gluten challenge
• Absence of celiac specific antibodies and of villous atrophy
Catassi C et al. Non‐Celiac Sensitivity: the New Frontier of gluten related disorders. Nutrient 2013;5:3839‐3853
Once diagnosed ‐ where to start?
•Transitioning to the gluten‐free diet:
• Label reading
• Finding foods that work
• Gluten‐free meal by meal
• Gluten‐free household
• Parties and family events
• School/college
• Individualize the plan
•Nutritional quality of diet
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Treatment
• Meet with a Dietitian knowledgeable in the gluten‐free diet (GFD)
• Gluten‐Free Diet for Life – avoidance of all sources of:– Wheat
– Barely
– Rye
• Antibodies should return to normal levels in 6 to 12 months
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Healthy Gluten‐Free Diet
• Fresh fruits and vegetables
• Fresh meat, fish, poultry, and eggs
•Milk and cheese
– Check flavored products and look for words indicating it is not gluten‐free, including: wheat, barley, rye, oats, and malt
•Oats have a different protein then the other three grains and preliminary studies suggest that oats are fine
• Issue of cross‐contamination in milling and manufacturing processes
• If incorporating oats into diet use only oats that are labeled pure, uncontaminated or certified gluten‐free
• Some clinics suggest to avoid gluten‐free oats for the first six months to one year after diagnosis until all symptoms have resolved and antibodies are normal
Other Sources of Gluten
• Dextrins
• Flavoring (malt)
• Modified food starch
• HVP, HPP, TVP
• Mono/Diglycerides
• Natural and artificial flavorings
• Seasonings
• Vegetable gums
• Soy sauce
• Marinates
• Salad dressings
• Communion wafers
• Broth (flour bones)
• Cross‐contamination
– Toaster
– Condiments
– Butter/peanut butter
– Colander
Reading Labels ‐sources of all ingredients
Non GF Alcohol Beverages
• Fermented alcohols
– beer
• Rootbeer (naturally made)
• Fruit Ciders with barley enzymes
• Distilled alcohols with flavoring added back that has gluten
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Gluten‐Free Beer• Anheuser‐Busch, Inc. – Redbridge
http://www.redbridgebeer.com
• Bard’s Tale Beer, Buffalo NY www.bardsbeer.com
• Les bieres de la Nouvelle France – La Messagere – www.lesbieresnouvellefrance.com
• Green ‐http://glutenfreebeers.co.uk/en/page/index.html
The Food Allergen Labeling and Consumer Act (FALCPA)
• Passed in the U.S. House of Representatives July 21, 2004
• This landmark legislation will require the top 8 food allergens (milk, eggs, peanuts, tree nuts, fish, shellfish, wheat and soy) to be listed on food labels by January 1, 2006.
• The bill also requires the FDA to develop rules for the use of the term 'gluten‐free' on product labels by January 2008.
Gluten‐Free Labeling Rule
• The GF labeling is a voluntary – manufacturers are not required to list “gluten” in their food products
• If the food is labeled gluten free it must meet the FDA’s requirements:– Inherently does not contain gluten(e.g., almonds, bottled water)
OR– Meets the following criteria
• Does not contain wheat, rye, barley or cross bred hybrids of these grains• May contain an ingredient that is derived from a gluten‐containing grain and has been processed to remove the gluten (e.g., wheat starch) as long as the food product contains less than 20 ppm
• Does not contain 20 ppm or more of gluten
AND– any unavoidable gluten in the food due to cross‐contact or migration of
gluten from packaging material is less than 20 ppm gluten.
• If a 1‐ounce (28.35 grams) slice of gluten‐free bread containing 20 parts per million gluten would contain 0.57 milligrams of gluten
• If you could take a one‐ounce slice of regular bread and break it into 7,030 tiny pieces, one of these tiny pieces would contain the same amount of gluten found in an entire one‐ounce slice of gluten‐free bread
Lunch 2 slices Glutino Bread w/fiber 220 702 oz turkey 70 01 tsp mustard 3 01 cup fruit salad 80 01 cup low fat milk 120 0
Afternoon Snack1 serving GF pretzels 190 40
Dinner1 serving of Brown Rice Pasta 200 1101/4 cup sauce 50 01/2 cup broccoli 30 03 oz meatballs 150 101 slice of Rice Bread 110 354 chocolate GF cookies 160 60
1953 393
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Nutrient Concerns of a GFD
• Iron
• Folate
• Calcium (absorbed in the proximal small intestine)
• Fat Soluble Vitamins – A,D,E,K
• Vitamin B12• Fiber
What’s is the Difference?
• Enriched grains are the primary source of iron, folic acid, B‐vitamins
• Most GF grains are not fortified
• Many GF flours are refined
• Other restrictions– Lactose
– FODMAP
– Other food intolerances (soy, corn)
Type 1 Diabetes & Celiac DiseaseStarting the Gluten‐Free Diet: What to Expect
Insulin: Onset, Peak, Duration How Food Affects the Blood Glucose
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Glycemic Index
White Bread or Glucose (standard) Legumes (beans)
1 hour 2 hour 1 hour 2 hour
A carb is not always a carb!
• 55g Carb • 7g Protein
• 16g Fat
• 25g Carb• 4g Protein
• 1g Fat
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1 Gluten‐Free English Muffin (105g) 1 English Muffin (57g)
Oatmeal & Blueberries Cornflakes, Banana & Milk
How to get 25‐30 grams Fiber in a Day! Breakfast Calories Fiber (g)1 cup GF oatmeal 166 41 cup lowfat milk 120 01 tbsp Ground Flax seed 37 1.9Raisins (0.5 oz small box) 42 0.5
Afternoon Snack1 serving lentil crackers (5) 110 1Vegetable Sticks (carrots & celery) 1 cup 13 1.11/2 cup hummus 100 3.6
Dinner1 serving of Quinoa Pasta (2 oz dry) 205 41/3 cup tomato sauce 74 2.21/2 cup broccoli 27 2.64oz salmon 206 01.5 cups salad (let, tom, carrot) 30 1.8Balsamic Vinegeratte (2 Tbsp) 20 0.1
1850 35.2
Choose whole-grain GF grains
•Include 2 cups of fresh fruit
•Include 2-3 cups of vegetables
Fiber Content of GF Grains & Flours(grams fiber per cup)
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Recommendations
• Meet with a dietitian knowledgeable in the GFD1. Review GFD
2. Nutrition assessment
• Multiple Vitamin
– Always check the label
• Suggest try whole GF grains
– Amaranth, buckwheat, millet, quinoa, tef,
• Encouraged increase GF foods that are high in iron, fiber and nutritionally rich
If Symptoms Continue?
• Review the GFD diet with RD– Use only GF products
• Other intolerances– Lactose– FODMAPS ‐ Fermentable, Oligo‐, Di‐, and Mono‐saccharides And Polyols are low‐fermentable, poorly absorbed, short chained carbohydrates
• Does not check blood glucose- last A1c 6.4%, MD goal is 6.0%
• BMI 26.9
• “Gets shaky every morning between breakfast and lunch”
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Case Study ‐ LM
• Eats six small meals a day
• Gained 10 lbs. since starting the GFD
• Sleep apnea is worsening
• Diet Recall: ~1,600 calories/day
• Estimated Energy Needs – 1,500 calories/day
• Feels he has an excellent understanding of the GFD
• Why are you here today?
• “I need a list of healthy, low fat, low carb, low calorie snacks and I do not like any fruits or vegetables”
Smartphone AppsShopping
• Allergy & Gluten Free Diet Tracker by Fooducate ‐ www.fooducate.com ‐ $9.99 – can scan barcode to product or by category. Can see if the product contains the following allergens: gluten, milk, lactose, tree nuts, peanuts, soy, , fish, shellfish, and soy ‐ iOS, Android
• Is That Gluten‐Free? – $7.99 ‐ has a database of 20,000 GF manufacturer verified GF products from more than 660 brand names. Search by category, brands, ingredients or keywords. ‐ iOS, ipad
Eating Out
• AllergyEats Mobile – www.allergyeats.com ‐ Free – Provides user‐based feedback on how a restaurants accommodation of diners with food allergies. The search can be customized by allergen (gluten,dheat, corn, dairy, eggs, fish, peanuts, shellfish, soy and tree nuts), location, or the “Find Near Me” option. ‐ iOS, android
• Dine Gluten Free – www.glutenfreetravelsite.com – Free – Peer review of gluten‐free or friendly businesses in the USA or around the world. Search by locations including restaurants, bakeries, markets, hotels, B&B’s, cruises, and colleges – iOS, Android
• Find Me Gluten Free – www.findmeglutenfree.com – Free – search gluten‐free dining options by entering specific locations or browse the “Popular Chains” option which also links you to the restaurants website and GF menu. Has reviewer tips and share information ‐iOS, Android
• iCanEat OntheGo Gluten Free & Allergen Free – www.glutenfreepassport.com ‐$2.99 – has 34 USA food chains and can search by allergen ‐ iOS, Android
• iEatOut Gluten & Allergen Free ‐ www.glutenfreepassport.com ‐$2.99 – searches seven ethnic cuisines including Chinese, French, Indian, Italian, Mexican, steak and seafood, and Thai ‐ iOS, Android
Traveling
• Gluten Free and Allergy Free Travel Dining Cards – www.glutenfreepassport.com/allergy ‐gluten‐free‐travel/gf‐translation‐cards ‐ Free ‐ dining cards is 13 different languages to help with dining out and communication your food concerns when ordering meals in a foreign‐speaking countries. ‐ iOS, Android
• Gluten Free Restaurant Cards from Celiac Travel.com – www.celiactravel.com – Free – has GF restaurant cards in 54 languages when dining out.
Support Groups Organizations
• National – American Celiac Society Dietary Support Coalition– Celiac Sprue Association/USA – Celiac Disease Foundation – Gluten Intolerance Group
• Massachusetts– New England Celiac Organization (NECO) formally known as
Healthy Villi – www.healthyvilli.com
• Celiac Centers – BIDMC Celiac Center – Mass General Celiac Center – HCCR – Harvard Celiac Center of Research – Includes BIDMC,
Mass General, Children’s Hospital, Joslin Diabetes Center,
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www.celiac.com
Cooking Classes
• Culinary Institute of America‐http://www.ciachef.edu/newyork gluten‐free baking classes
• Gluten Free Cooking With Oonagh – Oonagh Williams http://www.youtube.com/channel/UCWLusJC8wu3aiY6FQCA00gQ
• Registration is now open for the All About Food Autumn Workshop Afternoon. This event will be held on Sunday November 2 at Four Points by Sheraton in Norwood, MA. Check-in begins at 12:30 p.m.
• Learn how to make delicious Indian dishes with Chef Shilpi Ranjan!• Bake wonderful Thanksgiving treats with Gillian O'Callaghan!• Discover safe gluten free dining out tips from Burtons Grill!• Attend the Newly Diagnosed workshop to learn about the gluten free diet,
reading labels, dining out and other tips!
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Celiac Program at Harvard Medical School
Mass General Hospital Celiac Center – Alessio Fasano, MD
Beth Israel Deaconess Hospital – Ciaran Kelly, MD
Boston Children's Hospital, Alan Leichtner, MD
Joslin Diabetes Center – Lori Laffel, MD
Mission: “To increase knowledge and awareness of celiac disease and other gluten‐related disorders in order to improve healthcare delivery, quality of life, and support for the gluten‐free community.”
Activities: The Celiac Program at HMS will be engaged in education, training of health care professionals, and basic, clinical, and translational research focused on gluten‐related disorders