Living Gluten-free

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• Living Gluten-free
• in a
• Gluten-filled World

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Objectives

• Overview of celiac disease and gluten sensitivity
• Discuss common nutrient deficiencies
• Identify foods to choose
• Discuss strategies for navigating the grocery
  store
• Recognize food prep strategies to avoid cross
  contamination
• Cite tools available

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What is Celiac Disease?

• Celiac disease (CD) is a genetically linked
  disease with an environmental trigger.
• Eating certain types of protein fractions,
  commonly called gluten, sets off an autoimmune
  response that causes damage to the small
  intestine.

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The Diagnosis for CD 3 Steps

• Physical examine including blood tests for gluten
  antibodies (IgA based tests)
• EMA anti-endomysial
• TTG anti-tissue transglutaminase
• DGP Deaminated Gliadin Peptide
• A small bowel biopsy
• Implement the gluten-free diet
• (process complete when symptoms subside)

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What is non-celiac gluten sensitivity?

• Nonallergic and nonautoimmune response
• to gluten
• Is thought not to cause damage to the small
• intestine
• Individual tests negative for celiac disease
• and wheat allergy but has adverse
• response to gluten
• Diagnosis remains one of exclusion

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Celiac Disease and Non-Celiac Gluten Sensitivity

• Gluten Sensitivity

• Celiac Disease

• non-autoimmune (test negative)
• non-allergic (test negative)
• normal biopsy
• complications not known
• no consensus on diagnostic criteria
• diagnosis remains one of exclusion

• autoimmune
• IgA, TTG (or others) positive
• biopsy shows damage
• associated with complications

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CD Prevalence in the U.S.

• 1 133 Average healthy people
• At Risk Groups
• 156 Related symptoms
• 139 2nd degree relatives
• (aunt, uncle, cousin)
• 122 1st degree relatives
• (parent, child, sibling)

Fasano A, et al. Arch Intern Med 2003 Feb
10163(3)286-92.
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Statistics..celiac disease

• Celiac disease affects at least 3 million
  Americans
• 97 are undiagnosed
• The average rate of diagnosis is 4 years
• Delay causes risk for developing
• autoimmune disorders
• neurological problems
• osteoporosis
• cancer

Characteristics of adult celiac disease in the
USA results of a national survey. Green, P.H.
et.al. American Journal of Gastroenterology,
2001, 2006.
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Statistics..gluten sensitivity
Study from Naples, Italy estimates six
percent of the U.S. population, or 18 million
people, suffer from gluten sensitivity (gs)
Journal of Internal Medicine Vol 269 No 6, June
2011 Review of May Symposium Celiac
Disease Sapline A . Divergence of gut
permeability and mucosal immune gene expression
in two gluten-associated conditions celiac
disease and gluten sensitivity. BMC Med. 2011 Mar
9923.
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National numbers adding up..

3,128,450 1 Celiac Disease (CD) 18,772,705 6
Gluten Sensitivities (GS) ________________________
__________________ 21,901,000 7 Total Estimate
with CD or GS
.
US Census Bureau as of 8/22/11 312,045,081
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Omaha numbers adding up..

4,090 1 Celiac Disease (CD) 24,540 6 Gluten
Sensitivities (GS) ______________________________
_________ 28,630 7 Total Estimate in Omaha
with CD or GS
Omaha CSA Chapter has 1700 names assuming 50
contact CSA the diagnosis rates are likely
higher in this area
.
Census Data 2010 for NE and Omaha, 1,826,341 and
408,958 respectively
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National numbers adding up..

3,128,450 1 Celiac Disease (CS) 18,772,705 6
Gluten Sensitivities (GS) ______________________
____________________ 21,901,000 7 Total
Estimate with CS or GS
.
US Census Bureau as of 8/22/11 312,045,081
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Symptoms..over 300

• Emotional
• Depression
• Disinterest in normal activities
• Irritability
• Mood changes
• Inability to concentrate

• GI
• Diarrhea or constipation
• Abdominal cramping and bloating
• Flatus (Passing Gas)
• Constipation
• Fat in stool
• Malabsorption resulting in nutrient deficiencies

www.csaceliacs.org
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Symptoms..

• Other
• Anemia
• Appetite changes
• Decreased ability to clot blood
• Decreased fat padding feet/buttocks/hands
• Dehydration

• Delayed puberty
• Edema
• Electrolyte imbalance
• Fatigue
• Gluten ataxia
• (failure of muscle coordination)
• Infertility/miscarriages

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Symptoms..

• Osteopenia
• Osteoporosis
• Pain in bones and joints
• Very dry skin
• Weakness
• Weight loss (unexplained)
• Dermatitis Herpetiformis

• Other
• Mouth sores or cracked lips
• Smooth or geographic tongue
• Tooth enamel defects
• Muscle cramping
• (hands and legs)
• Night blindness
• Nutrient deficiencies

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Other associated conditions.

• Autoimmune Diseases
• Type 1 Diabetes
• Thyroid Disease
• Addisons Disease
• Sjorgens Syndrome
• Rheumatoid arthritis
• Autoimmune hepatitis
• Vitiligo
• Raynauds Disease

• Malignancies
• Enteropathic-associated T-cell lymphoma
• Small bowel adenocarcinoma
• Esophageal squamous carcinoma
• Oropharyngeal squamous carcinoma
• Dermatitis Herpetiformis

Health Hazard Assessment for Gluten Exposure in
Individuals with Celiac Disease Determination
of Tolerable Daily Intake Levels and Levels of
Concern for Gluten. May 2011.
http//www.fda.gov/downloads/Food/ScienceResearch/
ResearchAreas/RiskAssessmentSafetyAssessment/UCM26
4152.pdf
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Symptoms in Children

• How is the child developing?
• Slowly
• Not gaining weight
• Losing weight
• Under age three
• Growth failure
• Diarrhea
• Projectile vomiting
• Abdominal bloating/distention

• Older children
• Crankiness
• Difficulty concentrating
• Irritability
• Personality changes
• Poor memory

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The Diet is the Prescription!
Medical Nutrition Therapy Dietitians are the
Nutrition Experts
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Three Step Approach A Self-Management Guide to
the GF Diet

• Step 1 Foundation
• Basic self-management
• Begin healing
• Make risk-free choices
• Choose naturally gluten-free foods
• Eliminate wheat, barley, rye, common oats,
  crosses
• and derivatives
• Become knowledgeable Prepared by Jean Guest,
  PhD, RD, LMNT

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Three Step Approach A Self-Management Guide to
the GF Diet

• Step 2 Expansion
• Intermediate self-management
• Symptoms resolving
• Evaluate choices
• Address intolerances and allergies
• Continue knowledge process

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Three Step Approach A Self-Management Guide to
the GF Diet

• Step 3 Maintenance
• Advanced self-management
• Habits for optimal health
• Evaluate and update plan
• Living a full life

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Most Common Nutrient Deficiencies

• Iron
• B-12
• Folic Acid
• Calcium
• Vitamin D
• Fiber

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Sources of Heme-Iron
Food Iron (mg) DV
Beef, chuck, lean only, braised, 3 oz 3.2 20
Turkey, light meat, roasted, 3½ oz 1.6 8
Chicken, breast, roasted, 3 oz 1.1 6
Pork, loin, broiled, 3 oz 0.8 4
Tuna, white, canned in water, 3 oz 0.8 4
U.S. Department of Agriculture, Agricultural
Research Service. 2003. USDA Nutrient Database
for Standard Reference, Release 16. Nutrient Data
Laboratory Home Page, http//www.nal.usda.gov/fnic
/foodcomp
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Sources of Non-heme Iron
Food Iron(mg) DV
Chex Cereal, ¾ c 9 50.00
Soybeans, mature, boiled, 1 c 8.8 50.00
Beans, kidney, mature, boiled, 1 c 5.2 25.00
Molasses, blackstrap, 1 T 3.5 20.00
Spinach, boiled, drained, ½ c 1.9 10.00
U.S. Department of Agriculture, Agricultural
Research Service. 2003. USDA Nutrient Database
for Standard Reference, Release 16. Nutrient Data
Laboratory Home Page, http//www.nal.usda.gov/fnic
/foodcomp
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Sources of B-12
Food B-12 (mcg) DV
Trout, rainbow, farmed, cooked, 3 oz 5.4 90.00
Salmon, sockeye, cooked, 3 oz 4.9 80.00
Beef, top sirloin, broiled, 3 oz 2.4 40.00
Breakfast Cereals, fortified with 25 B12 (Chex Cereal, 3/4c) 1.5 25.00
Yogurt, plain, 1 cup 1.4 25.00
Milk, 1 cup 0.9 15.00
Egg, large, 1 whole 0.6 10.00
U.S. Department of Agriculture, Agricultural
Research Service. 2003. USDA Nutrient Database
for Standard Reference, Release 16. Nutrient Data
Laboratory Home Page, http//www.nal.usda.gov/fnic
/foodcomp
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Sources of Folate/Folic Acid
Food Micrograms(µg) DV
Chex Cereal, fortified with 50 of DV, 200 50.00
Spinach, frozen, cooked, boiled, ½ c 100 25.00
Great Northern beans, boiled, ½ c 90 25.00
Asparagus, boiled, 4 spears 85 20.00
Rice, white, long-grain, parboiled, enriched, cooked, ½ c 65 15.00
U.S. Department of Agriculture, Agricultural
Research Service. 2003. USDA Nutrient Database
for Standard Reference, Release 16. Nutrient Data
Laboratory Home Page, http//www.nal.usda.gov/fnic
/foodcomp
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Food Sources of Calcium
Food Calcium(mg) DV
Yogurt, plain, low fat, 8 oz 415 42.00
Sardines, canned in oil, with bones, 3 oz 324 32.00
Cheddar cheese, 1.5 oz 306 31.00
Milk, nonfat, 8 oz 302 30.00
Mozzarella, part skim, 1.5 oz 275 28.00
Orange juice, calcium-fortified, 6 oz 200-260 20-26

U.S. Department of Agriculture, Agricultural
Research Service. 2003. USDA Nutrient Database
for Standard Reference, Release 16. Nutrient Data
Laboratory Home Page, http//www.nal.usda.gov/fnic
/foodcomp
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Food Sources of Vitamin D
Food Vit D (IU's) DV
Cod liver oil,1T 1360 340.00
Salmon, sockeye, cooked, 3oz 794 199.00
Tuna fish, canned in water, drained, 3 oz 154 39.00
Milk, nonfat, reduced fat, and whole, vitamin D-fortified, 1 c 115-124 29-31.00
Orange juice fortified with vitamin D, 1 c (check product labels, as amount of added vitamin D varies) 100 25.00
Yogurt, fortified vitamin D, 6 oz (more heavily fortified yogurts provide more of the DV) 80 20.00

U.S. Department of Agriculture, Agricultural
Research Service. 2003. USDA Nutrient Database
for Standard Reference, Release 16. Nutrient
Data Laboratory Home Page, http//www.nal.usda.gov
/fnic/foodcomp
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Non-Food Sources of Vitamin D

• Be sensible!! Don't burn!
• 5 - 10 minutes per day
• 30 minutes 20,000 IU's

VitaminDHealth.org
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Food Sources of Fiber

Food Fiber (g)
Wild Rice, ½ c 4.5
Flax Seed, 2 T 6
Raspberries, ½ c 4
Baked Beans, canned, plain, ½ c 5.2
Sweet potato, cooked, no skin, 1 medium 3.9
Almonds, 1 oz 3.3
Jean E. Guest, PhD, RD, LMNT. Fiber! Fiber!
Fiber! CSA Lifeline Volume XXVII, 2007. Tricia
Thompson, MS, RD and Suzanne Simpson, RD.
Counting Gluten-Free Carbohydrates 2010. Located
at http//csaceliacs.org/.
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Supplement Savvy

• GF Multivitamin
• GF B-Complex Vitamin
• GF Vitamin D
• GF Calcium
• Talk with your health care team!

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Where is gluten found?...

• wheat
• barley
• rye
• oats (unless gf)
• (WBRO)

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Additional sources of gluten.
A gluten-free diet means no

• Wheat
• wheat flour, AP flour, wheat bran, wheat starch,
  wheat germ and other forms of wheat
• -Durum -Emmer -Kamut -Semolina
• -Triticale -Spelt -Einkorn -Graham
• -Seitan - Bulger - Couscous - Faro

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Gluten-free basic choices

• Gluten-free foods include
• Fresh salad (no croutons)
• Fruits and vegetables
• Milk
• Meats, fish or poultry
• (no breading, no marinade)
• Pure spices and herbs
• (watch out for seasonings)
• Pasta and breads labeled gluten-free

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Preparing for the grocery store
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FDAs Proposed Definition of Gluten-Free

• Cannot contain wheat, barley, rye (W, B, R)or a
  crossbred hybrid of these grains
• Cannot contain ingredient derived from W, B, R
  that has not been processed to remove gluten
• Can contain an ingredient derived from W, B, R
  that has been processed to remove gluten but with
  final product containing lt 20 ppm gluten
• Must contain lt20 ppm or more gluten, whether
  gluten comes from an ingredient or is in the food
  unintentionally due to cross contact

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How to know if something is gluten-free?

• CSA
• Recognition Seal
• lt 5 ppm

GIG Certification lt 10 ppm
NFCA Certification lt10 ppm
Health Canada dictates - 20 ppm is guide
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Regulatory Agencies

• FDA
• Regulates all foods except meat, poultry egg
  products
• FALCPA covers all packaged foods in the US except
  those covered by the USDA

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Label reading know how.
8 Allergens
Eggs Fish Milk Peanuts Shellfish Soybeans Tree nuts Wheat
Food Allergy Labeling and Consumer Protection Act
(FALCPA) requires only top 8 allergens to be
identified. Barley, rye, oats and their
derivatives are not required to be listed.
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Label reading know how.

• Food Allergy Labeling and Consumer Protection Act
  (FALCPA) requires the 8
• top allergens to be identified.
• Barley, rye, oats and their derivatives are not
  includedkeep an eye out for malt and brewers
  yeast too.

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Regulatory Agencies

• USDA
• Regulates meat, poultry and eggs
• No allergen labeling requirements at this time
• If there is a Contains statement the
  manufacturer is voluntarily complying with FALCPA

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Label Reading Savvy Ex 1

• Is this nutrition bar gluten-free?
• Ingredients Whole Grain Oats, Maltose Corn
  Syrup, Sugar, Rice Flour, Almonds, Honey, Dried
  cranberries, Fructose, Canola Oil, Maltodextrin,
  Dried Pomegranate Arils, Soy Lecithin, Salt, Malt
  Extract, Baking Soda, Natural Flavor.
• CONTAINS ALMOND, SOY MAY CONTAIN PEANUT AND
  SUNFLOWER INGREDIENTS

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Label Reading Savvy Ex 2
Modified Food Starch USDA product may include
modified food starch and wheat might not be
stated on the label Natural Flavorings USDA
product containing protein from W, B, R, the
flavoring ingredient must be listed in the
ingredients list by its common or usual
name Bottom line call on ? products
Frozen Turkey Ingredients Turkey, Water, Salt,
Modified Food Starch, Sodium Phosphates, Natural
Flavorings
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Navigating the grocery store

• Speciality areas may be located within the store
  with gluten-free items
• Select package items rather than bulk bins
• Select products with gluten-free seals whenever
  possible (especially grains, seeds, and flours)

Thompson T, Lee AR, Grace T. Gluten
contamination of grains, seeds, and flours in the
United States a pilot study. Am Diet Assoc 2010
Jun110(6)937-40.
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Hidden Sources of Gluten
The Three Cs Content, Contact, Contamination

• Content - Foods

• Foods injected with broth
• Modified food starch
• Sauces
• Soy sauce
• Seasonings
• Processed foods
• Cold cuts, deli foods, pre-cooked foods, frozen
  foods

• Breading
• Brewers Yeast
• Broth
• Brown rice syrup
• Casseroles
• Croutons
• Gravies

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Hidden Sources of Gluten The Three
Cs Content, Contact, Contamination

• Content and Contact Other Items

• Manufacturing
• Flour dust in air
• Flour on conveyor belts
• School
• Play dough
• Paints
• Crayons

• Personal Care Items
• Lipstick, make up
• Lotions
• Medications

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Tips to avoiding cross-contact

• Separate area and items needed to avoid
  cross-contact
• Strainers
• Utensils, Parchment Paper
• Toaster Oven
• Designated Prep Area or Station

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What are healthy and tasty gluten-free grains?

• Brown rice
• Whole Corn
• Millet
• Teff
• Sorghum
• Wild Rice
• Buckwheat
• Amaranth
• Quinoa
• Gluten-Free Oats? Not recommended until 1 year
  on gluten-free diet then self-assessment and
  antibody testing recommended

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Gluten-Free Sources of Fiber

• Almond
• Amaranth
• Buckwheat
• Cornmeal, corn bran
• Flax seed and meals, Chia seed
• Bean (garbonzo, garfava, black, white, pinto,
  navy, soy, kidney)

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Gluten-Free Sources of Fiber

• Indian wheat grass (Montina)
• Millet
• Rice bran
• Brown rice flour
• Soy flour
• Teff
• Quinoa
• Pea Hull Fiber

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Discover New Foods

• Amaranth used in ancient civilizations, robust,
  nutty flavor
• Buckwheat actually is a fruit and a relative of
  rhubarb, nutty flavor
• Flax size of sesame seed, grind to improve
  nutrient absorption

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Discover New Foods

• Millet closely related to corn, nutty flavor
• Indian rice grass sweet, nutty, almost wheat
  like flavor
• Quinoa strong flavor, combine with other flours
  or foods
• Sorghum nutty flavor

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Discover New Foods

• Teff grass, mild molasses-like flavor, more
  nutritious than common grains
• Wild rice is not a member of the rice family,
  nut-like flavor
• Reference Case, Shelley, Gluten-Free Diet,
  April 2006, www.glutenfreediet.ca

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Kitchen Pantry Smarts!

• Keep gf items in separate container
• Keep gf items above other items

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Resources Support Groups

• Celiac Sprue Association www.csaceliacs.org

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What does a support group provide?

• Resources for daily living that are based on
  science and research
• Life long friendships to journey the path of
  living gluten-free
• National support from headquarters
• As RD, need to help groups filter information

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ADA Resources

• Evidence Analysis Library (EAL) 2009
• Evidence-based Nutrition
• Practice Guidelines for Celiac Disease
• www.adaevidencelibrary.com

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ADA Resources

• Celiac Disease Toolkit based on the EAL
  data,visit www.eatright.org for more information
• DIGID-Dietitians in Gluten Intolerance Diseases
  (a sub- unit of the Medical Nutrition Practice
  Group) www.mnpg.org

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CSA Resources

• CSA Web-site www.csaceliacs.org
• Toll Free 877-272-4272
• Local Support Group Information
• Three Step Diet Approach (Self-Mngt Approach)
• Counting Gluten-Free Carbohydrate Guide!!!
• Just download, its free!
• Fact Sheets on Common Nutrient Deficiencies

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CSA Tools CSA Gluten-Free Product Listing
Available - CD - Spiral Bound Book -
iPad or iPhone App GlutenFreeMe
http//itunes.apple.com/us/app/glutenfreeme

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Other resources

• Grocery Store Gluten-Free Listings
• Hy-Vee Example http//www.hy-vee.com/meal-soluti
  ons/special-diets/default.aspx
• NIH Teaching Materials
• http//www.celiac.nih.gov/Materials.aspx
• Gluten Free Drugs
• www.glutenfreedrugs.com

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Gluten-free living!
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Activity

• Break into 6 groups
• Plan gluten-free options for one of the
  following
• - childrens birthday party
• - evening catered evening event at Joslyn
• - bed and breakfast
• - hospital mother just delivered baby
• - bar and grill
• - assisted living center

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Thank you!

• Shelly Asplin, MA, RD, LMNT
• Celiac Sprue Association
• shelly.a_at_csaceliacs.org
• PO Box 31700 Omaha, NE 68131-0700
• Toll Free 877-CSA-4CSA Fax [phone]
• www.csaceliacs.org
• www.facebook.com/csaceliacs
• www.twitter.com/csaceliacs