The Compliance Of Celiac Disease Patient's to Dietary Regimen Seminar in Clinical Nutrition CHS439 Done by : Al-moushawah, Nahlah, AL-Baijan Norah. and.

The Compliance Of Celiac Disease Patient's to Dietary Regimen

Seminar in Clinical NutritionCHS439

Done by : Al-moushawah , Nahlah , AL-Baijan Norah . and Abo

rasien , EbtehalSupervision by:

Dr. Saada Al-Orf T. Nouf Al-Gamdy

Outline: introduction oHistory of celiac diseaseoClassification and Symptom of celiac diseasePresented by :Norah AL.Bajan

oPrevalance of celic disease presented by :Ebtehal Aburasain

o

oDiagnosis of celiac disease oCoues of celiac disease presented by : Nahla Almoshawah

oManegment of celiac diseaseoAlternative treatment of celiac diseasepresented by :Ebtehal Aburasain

objective: Will be conducted to study the compliance of celiac disease patient to investigate the difficulties they are

facing .

History of celiac disease: In report entitled "On the Celiac Affection" disease was first described by Samuel Gee in 1888. Willem k. dick (Dutch pediatrician) is recognized an association between the consumption of bread and cereals and relapsing diarrhea (1). This observation was in Second World War 2 when there was a shortage of bread and cereals, so the symptoms improved once the bread was replaced by non –cereal containing foods (1).

1-Faiza A. Qari . Clinical presentation of adult celiac disease

in Western Saudi Arabia. Saudi Med J 2002; Vol. 23 (12): 1514-1517.

Introduction:

CD it is also known as • celiac sprue . • gluten – sensitive enteropathy .• nontropical sprue (4; 5).

4- Celiac disease . National Digestive Diseases Information Clearinghouse5- J. Bai , E. Zeballos, M. Fried, G.R. Corazza , D. Schuppan, M.J.G. Farthing, C. Catassi , L. Greco, H. Cohen, J.H. Krabshuis, celiac

disease, World Gastroenterology Organisation Practice Guidelines,2007

definition of celiac disease:

Celiac disease (CD) permanent autoimmune mediated and food sensitive enteropathy caused by the ingestion of gluten containing cereals (2).

Gluten is alcohol soluble protein component of the cereals wheat, rye, and barly (2) and poorly digested in human upper gastrointestinal tract .

2-Marco Silano, Carlo Agostoni ,and Stefano Guandalini . Effect of the timing of gluten introduction on the development of

celiac disease . World Journal of Gastroenterol . 2010 April 28;16(16):1939-

1942.

genetic

environmental factors

gluten and immunity

CD is amultifactorial condition originating from interaction between

2-Marco Silano, Carlo Agostoni ,and Stefano Guandalini . Effect of the timing of gluten introduction on the development of celiac disease . World Journal of Gastroenterol . 2010 April 28;16(16):1939-

1942.3-Peter H.R. Green , and , Christophe Cellier . Celiac Disease . The New England Journal of

Medicine . 2007 october 25 357 ; 17 ..

Gluten

Effect of CD patient

Damage of

small

intestinal

mucosa

Poorly absorption of

nutrien

t

.

Barly

rye

Wheat

3-Peter H.R. Green , and , Christophe Cellier . Celiac Disease . The New England Journal of Medicine . 2007 october 25 357

; 17.

3

Classification and Symptom of celiac disease:

Symptoms may occur in the digestive system or in other part of the body and it vary from person to

person greatly according to age group (3; 6) .

3-Peter H.R. Green , and , Christophe Cellier . Celiac Disease . The New England Journal of Medicine . 2007 october 25 357 ; 17 .

6 -Celiac disease . National Digestive Diseases Information Clearinghouse

6

Classification of celiac disease (4):

CD can be divided into the following forms :

Classical (typical)

Atypical

Silent

• chronic diarrhea( 20-18.5%)• Anorexia

• abdominal distention

Mostly gastrointesti

nal

• Iron deficiency (20-80%)•Dental enamel hypoplasia (30%

of untreated patient with CD )

Mostly Not gastrointesti

nal

Asymptomatic

4-Alessio fasano and carlo catassi . Current Approaches to Diagnosis and Treatment of Celiac Disease : An Evolving Spectrum , the American

gastroenterological association . 2001 120 (3) 636-651.

Prevalence of Celiac Disease:

• Celiac disease is common throughout the world and affects around (1:100 -300) of the population.

• The true prevalence of CD is difficult to be estimated because of its variable clinical presentation, it occurs frequently without gastrointestinal symptoms.

• The female-to-male ratio is 2:1.

7-D.BRANSKI, A. FASANO, AND R.TRONCONE. LATEST DEVELOPMENTS IN THE PATHOGENESIS AND TREATMENT OF CELIAC DISEASE. The Journal of Pediatrics ,

September .2006.295-300.

Europe

Africa

Asia

country percent country percent

in Brazil 1:681 in Sweden 1:250

in Italy 1:106 in Denmark 1:524

in Portugal 1:134 in Holland 1:333

in Switzerland 1:132 in Israel 1:157

in Spain 1:118 in the USA 1:250

Back

country percentTunisia 1:157

Back

country percent country percent

Iran 1:166 India 1:500-1:20,000

Syria 1.5:100 Turkey 1:87

Back

Saudi Arabia ..The study was done in the western region of Saudi Arabia, the results

showed that eighty children were identified with a diagnosis of CD. Their age range, (0.5-18 years).

41

51%detected during screening of high-

risk groups8-Pubmed.gov,[internet].Celiac Disease in Children and Adolesents at Asing Centre in SaudiArbia,2002,

[updated2011Jan.-Feb.]availableat http://www.ncbi.nlm.nih.gov/pubmed/21245600.

11-Kirby Sainsbury , Barbara Mullan. Measuring beliefs about gluten free diet adherence in adult coeliac disease using the theory of planned behavior. Appetite 56 (2011) 476-483.

Not everyone with CD symptom it is mean they have the disease ,because the symptoms of CD are similar for other disease ,and it can be misdiagnosed with irritable bowel syndrome (IBS) ,Iron deficiency anemia ,chronic fatigue syndrome and other.

Diagnosis of celiac disease:

Endoscopy

Screening test

Blood test (serologic)

10-J. Bai , E. Zeballos, M. Fried, G.R. Corazza , D. Schuppan, M.J.G. Farthing, C. Catassi , L. Greco, H. Cohen, J.H. Krabshuis, celiac disease, World Gastroenterology Organisation Practice Guidelines,2007.

Clinical suspicious(not on gluten free diet)

High low

IgA tissue transglutaminaseOr

IgA endomysial antibody+

Total serum IgA level

Small bowel biopsy +

IgA tissue transglutaminase or endomysial antibody

Either test positive All test negative

Small bowel biopsy Diagnosis excluded

stage -2- if present of crypyhyperplasia and inflammatory infiltrates in the lamina propria .

J. Bai , E. Zeballos, M. Fried, G.R. Corazza , D. Schuppan, M.J.G. Farthing, C. Catassi , L. Greco, H. Cohen, J.H. Krabshuis, celiac disease, World Gastroenterology Organisation Practice Guidelines,2007

Rodrigo L. ,Celiac disease, World J Gastroenterol 2006 novamber; 12(41): 6585-6593 www.wjgnet.com/1007-9327/12/6585.asp.

0-diagnosed with normal duodenal biopsy

stage-1-increasedon percentage of intraepithelial lymphocyte to (IEL)above 30% .

stage -4- total hypoplasia of the mucosa .

stage -3- atrophy of villi .

Genetic :The most important genetic factors identified are HLA-DQ2 and HLA-DQ8, which are necessary but not sufficient to predispose to CD. Practically 90%-95% CD patients carry HLA-DQ2 or HLA-DQ8.

Caues of celiac disease

population

Cause :Wheat ,rye and barley are cereals that CD patient act with CD patient as toxic material causing the signs or symptoms of celiac disease.

Higher risk population of CD developing:

Relatives10% increased the risk on first degree relatives.Iron deficiency anemia (IDA) 2% to 5% in a symptom patient ,but still higher in ( 10% to 15%) in symptomatic .

Type 1 diabetes mellitus it is range from 2% to 5% in adult and become higher in child with 3% to 8%.

11-AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease, gastroenterology,2006 octoper, 131:1977-1980.

Osteoporosis and bone mineralizationthe chance for CD happen ( 1.5%-3%).

Liver disease1.5% to 9.0% in patients with elevated transaminase levels Autoimmune thyroid disease,

between 1.5% to 6.7%, Reproductive disordersranges between 2.1% and4.1% in women with unexplained infertility

11-AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease,

gastroenterology,2006 octoper, 131:1977-1980.

Breastfeeding

All the observational epidemiological studies dealing with the effect of breastfeeding on development of CD and found that children being breastfed at the time of gluten introduction had a 52% reduction in risk of developing CD, compared to their peers who were not breastfed at the time of gluten introduction .

Other possible factors

Marco Silano, Carlo Agostoni ,and Stefano Guandalini . Effect of the timing of gluten introduction on the development of celiac disease . World Journal of Gastroenterol . 2010 April 28;16(16):1939-1942.

Infectious Episodes

It is contribute to the development of CD by change the primibility and the cytokine balance in the intestinal represent an independent risk factor for celiac disease in genetically susceptible individuals to celiac disease.

Victorien M. Wolters .Cisca Wijmenga, Genetic Background of Celiac Disease and Its Clinical Implications Am J Gastroenterol. 2008;103(1):190-195.

Medication On treatment of hepatitis C with interferon (IFN) CD has been reported during this course of treatment .Silent form of CD should be suspected subsided in almost all patients after IFN was withdrawn and without a gluten-free diet but the historical abnormalities .

13-Victorien M. Wolters .Cisca Wijmenga, Genetic Background of Celiac Disease and Its Clinical Implications Am J Gastroenterol. 2008;103(1):190-195

Management strategies:

• Treatment consists of life-long avoidance of gluten-containing foods that is gluten free diet (GFD), such as (bread, cereal, cakes, and other food products or additives containing wheat, rye, and barley).

• Complete healing is expected, once gluten is removed from diet (14) .

• Medications and over the counter products may also contain gluten.

• The Treatment of CD is not the same of other chronic diseases because it is unavoidably in the patient's own hands(15).

14-A.Bellini, C.Zanchi, S.Martelossi, G.Leo, T.Not, and A.Ventura.Compliance with Gluten-free Diet: The Role of Locus of control in Celiac Disease.The Journal of Pediatrics.463-466

15-A.Fasano.Surprises trom Celiac Disease. SCIENTIFIC AMERICAN, INC.2011,2009.

Alternative Treatments:

• A gluten-free diet is effective and safe and at present is the only available treatment for CD.

• Any alternative treatments in the future must have a safety and effective profile equivalent to that of the GFD .

16 -Pubmed.gov,[internet].Celiac Disease in Children and Adolesents at Asing Centre in SaudiArbia,2002,

[updated2011Jan.-Feb.]availableat http://www.ncbi.nlm.nih.gov/pubmed/21245600.

Cont,

• Supplement therapy for patients with CD to help digest gluten peptides and thus not having any symptoms.

• By pretreatment of gluten-containing food and therefore not having supplements.

• Genetic engineering of wheat and inhibitory gliadin peptides.

Cont,

• Immunomodulatory strategist, that is a vaccine that would expose the immune system to small amounts of strongly immunogenic forms of gluten, on the theory that repeated small exposures would ultimately induce the immune system to tolerate gluten(17).

17 -Kirby Sainsbury , Barbara Mullan. Measuring beliefs about gluten free diet adherence in adult coeliac disease using the theory of planned

behavior. Appetite 56 (2011) 476-483.

Cont,

• Correction of the Intestinal Barrier Defect, It is an innovative therapeutic alternative in CD, because small intestinal permeability abnormalities are seen in untreated CD patients. The use of the zonulin inhibitor AT 1001 to correct intestinal barrier defects and AT 1001 has been shown to be well tolerated and to reduced gluten-induced intestinal barrier dysfunction, proinflammtory cytokine production, and gastrointestinal symptoms in celiac patients .

17 -Kirby Sainsbury , Barbara Mullan. Measuring beliefs about gluten free diet adherence in adult coeliac disease using the

theory of planned behavior. Appetite 56 (2011) 476-483.

Conclusion Celiac disease (CD) permanent autoimmune mediated

and food sensitive enteropathy caused by the ingestion of gluten containing cereals It is also known as celiac sprue, gluten – sensitive enteropathy, nontropical sprue. Classification of celiac disease are Classical (typical), atypical and silent. Celiac disease is common throughout the world and affects around (1:100 -300) of the population. The true prevalence of CD is difficult to be estimated because of its variable clinical presentation, it occurs frequently without gastrointestinal symptoms.

Con, • There are three key parameters for the

diagnosis of CD which are screening test, blood test (serologic) and endoscopy. Treatment consists of life-long avoidance of gluten-containing foods that is gluten free diet (GFD), such as (bread, cereal, cakes, and other food products or additives containing wheat, rye, and barley). Complete healing is expected, once gluten is removed from diet .

It is recommended to: Conducted a national survey to identify the extent of prevelance of CD in KSA . Design and implement a nutritional education program for all age group CD patients . Have joined cooperative effort between saudi food and drug uthority and the related ministries in order to;•Control the foods labeling.•Make the GFD products available in reasonable affordable price•Facilitate and encourage the local market to produce the GFD products.

Rerrerance 1-Faiza A. Qari . Clinical presentation of adult celiac diseasein Western Saudi Arabia. Saudi Med J 2002; Vol. 23 (12): 1514-1517.2-Marco Silano, Carlo Agostoni ,and Stefano Guandalini . Effect of the timing of gluten

introduction on the development of celiac disease . World Journal of Gastroenterol . 2010 April 28;16(16):1939-1942.

3-Peter H.R. Green , and , Christophe Cellier . Celiac Disease . The New England Journal of Medicine . 2007 october 25 357 ; 17 .

4- Celiac disease . National Digestive Diseases Information Clearinghouse5- J. Bai , E. Zeballos, M. Fried, G.R. Corazza , D. Schuppan, M.J.G. Farthing, C. Catassi , L. Greco, H.

Cohen, J.H. Krabshuis, celiac disease, World Gastroenterology Organisation Practice Guidelines,2007

6- Celiac disease . National Digestive Diseases Information Clearinghouse7-D.BRANSKI, A. FASANO, AND R.TRONCONE. LATEST DEVELOPMENTS IN THE PATHOGENESIS AND

TREATMENT OF CELIAC DISEASE. The Journal of Pediatrics , September .2006.295-300.8-Pubmed.gov,[internet].Celiac Disease in Children and Adolesents at Asing Centre in

SaudiArbia,2002,[updated2011Jan.-Feb.]availableat http://www.ncbi.nlm.nih.gov/pubmed/21245600 .

9-Kirby Sainsbury , Barbara Mullan. Measuring beliefs about gluten free diet adherence in adult coeliac disease using the theory of planned behavior. Appetite 56 (2011)

10-J. Bai , E. Zeballos, M. Fried, G.R. Corazza , D. Schuppan, M.J.G. Farthing, C. Catassi , L. Greco, H. Cohen, J.H. Krabshuis, celiac disease, World Gastroenterology Organisation Practice Guidelines,2007.

476-483.

11-AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease, gastroenterology,2006 octoper ,

131:1977-1980.

12-Marco Silano, Carlo Agostoni ,and Stefano Guandalini . Effect of the timing of gluten introduction on the development of celiac disease . World Journal of

Gastroenterol . 2010 April 28;16(16):1939-1942.

13-Victorien M. Wolters .Cisca Wijmenga, Genetic Background of Celiac Disease and Its Clinical Implications Am J Gastroenterol .

2008;103)1:(190-195.

14-A.Bellini, C.Zanchi, S.Martelossi, G.Leo, T.Not, and A.Ventura.Compliance with Gluten-free Diet: The Role of Locus of control in Celiac Disease.The Journal of Pediatrics.463-466

15-A.Fasano.Surprises trom Celiac Disease. SCIENTIFIC AMERICAN, INC.2011,2009.

16 -Pubmed.gov,[internet].Celiac Disease in Children and Adolesents at Asing Centre in SaudiArbia,2002,[updated2011Jan.-Feb.]availableat

17 -Kirby Sainsbury , Barbara Mullan. Measuring beliefs about gluten free diet adherence in adult coeliac disease using the theory of planned behavior. Appetite 56 (2011) 476-483.

http://www.ncbi.nlm.nih.gov/pubmed/21245600