Gluten Free & Healthy Living: sort the fads from the facts

Vandna Jerath, MD, FACOG
Community Health Seminar | Parker Adventist Hospital
drjerath.com | optimawomenshealthcare.com | optimavitalitymd.com
February 23, 2016
#glutenfree #healthyliving #factsvsfads
@drjerath @optimawhc @optimavitality

 FACOG – Board-Certified Ob/Gyn
 Private practice – 17 years
 Full scope obstetrics & gynecology
 Enjoy education and community outreach
 Disclosures – no financial affiliations
 Healthcare social media expert
 drjerath.com
 Gluten free for 2 ½ years
CommunityHealth Seminar | Parker Adventist Hospital | 2/23/2016

 General Ob/Gyn Services
 Women’s health resource/expert
 Female empowerment
◦ Be educated  Be engaged  Be empowered
 Spa-like setting
 Individualized, personalized, and compassionate care
 optimawomenshealthcare.com

 Center for Rejuvenation and Wellness
 Alternative, holistic, functional, integrative, and
complementary medicine
 BioTE® bioidentical hormone pellet therapy
◦ Treatmemt for both women and men
◦ Nutraceuticals
 MonaLisa Touch™ vaginal laser revitalization
 VitaMedMD™ vitamins and minerals

 To understand what gluten is and the impact it has on health.
 To learn about celiac disease including prevalence,
signs/symptoms, diagnosis, and management.
 To understand the evolving spectrum of gastroenterological
conditions, particularly regarding gluten and gluten
sensitivity.
 To understand the dietary restrictions of a gluten free diet.
 To be able to sort out the health vs. hype regarding gluten.

Source: Grow Magazine,Parker Adventist Hospital, Winter 2016, Volume 8, Issue 1, page 2

Photo source: someecards.comand glutenfreedude.com

 Jimmy Kimmel video
◦ http://www.youtube.com/watch?v=AdJFE1sp4Fw

 What is all the fuss?
◦ Less people eating gluten
◦ Revenue producing for the food industry - $15 billion in 2016
◦ Potentially life threatening for people with celiac disease
 May cause GI symptoms
◦ Allergy vs. sensitivity vs. intolerance
 Gluten free may be diet fad vs necessity
 Why?
◦ GMO crops?
 Possible overdiagnosis and overtreatment
 Media stories
◦ NY Times blog article – 9/29/2014
◦ Celiac Disease, a Common, but Elusive, Diagnosis
◦ http://well.blogs.nytimes.com/2014/09/29/celiac-disease-diagnosis-
gluten/?_php=true&_type=blogs&_r=0

Photo source: unearthedcomics.com

 Protein found in grains
◦ Wheat, barley, and rye
◦ Gliadin peptides
 Found in common foods
◦ Cereal
◦ Bread
◦ Baked goods
◦ Pasta
◦ Battered and possibly fried foods
◦ Malt
◦ Sauces, marinades, salad dressings, soy sauce, gravy
◦ May be hidden in processed foods
◦ Preservatives
◦ Beer

 Natural, plain, or unprocessed foods
◦ Meats/Poultry/Fish
◦ Fruits
◦ Vegetables
◦ Beans
◦ Dairy
◦ Nuts
Source: M. Dennis, S. Case, 2008 as appearedin PracticalGastroenterology,April 2004 and
BIDMC presentation by Daniel Leffler, MD, MS and Melinda Dennis, MS, RD, LDN.

 Safe grains, starches, & flours
◦ Rice
◦ Corn
◦ Soybeans
◦ Tapioca
◦ Potato
◦ Quinoa
◦ Millet
◦ Flax
◦ Arrowroot
◦ Amaranth
◦ Buckwheat
◦ Sorghum
◦ Millet
◦ Teff
◦ Nut flours (almond, pecan)
◦ Seed flours (sesame)
◦ Legume flours(garbanzo, lentil)
◦ Bean flours
Source: M. Dennis, S. Case, 2008 as appearedin PracticalGastroenterology,April 2004 and
BIDMC presentation by Daniel Leffler, MD, MS and Melinda Dennis, MS, RD, LDN.

Source: Thompson T. Celiac Disease Nutrition Guide, 2nd ed. Chicago:American Dietetic Association;2006.
Allowed Foods
amaranth
arrowroot
buckwheat
cassava
corn
flax
Indian rice grass
Job's tears
legumes
millet
nuts
potatoes
quinoa
rice
sago
seeds
sorghum
soy
tapioca
teff
wild rice
yucca
Foods To Avoid
•wheat including einkorn, emmer, spelt, kamut
•wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein
barley
rye
triticale(a cross between wheat and rye)
Other Wheat Products
bromated flour
durum flour
enriched flour
farina
grahamflour
phosphatedflour
plain flour
self-risingflour
semolina
white flour
ProcessedFoods that May Contain Wheat, Barley, or Rye*
bouillon cubes
brown rice syrup
candy
chips/potatochips
cold cuts, hot dogs, salami, sausage
communion wafers
French fries
gravy
imitationfish
matzo
rice mixes
sauces
seasonedtortilla chips
self-bastingturkey
soups
soy sauce
vegetablesin sauce
The Gluten-free Diet: Some Examples
In 2006, the American Dietetic Association updated its recommendations for a gluten-free diet. The following chart is based on the 2006 recommendations. This list is not
complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease
should always read food ingredient lists carefully to make sure the food does not contain gluten.

 Challenges
◦ Cross-contamination
◦ Hidden ingredients
◦ Preservatives
 Wheat free is not gluten free
 Not necessarily low fat or for weight loss
 Make sure adequate vitamins and minerals
 Vitamin B
 Vitamin D
 Calcium
 Fiber
 Iron
 Avoid
◦ Wheat
◦ Malt
◦ Modified food starch
◦ Dextrin
◦ Hydrolyzed wheat protein
 DO NOT START w/o confirming or ruling out celiac disease

 Digestive disease that damages small intestine
◦ Damaged villi of the small intestine
◦ Malabsorption of nutrients
◦ Celiac disease (CD), Celiac sprue, nontropical sprue, gluten-sensitive enteropathy
 Autoimmune reaction
 Intolerance to gluten
◦ How does it start?
◦ Surgery, infection, cereal < 3mo age, hereditary?
 Prevalence 1 in 100
 Women > Men
◦ 2/3 of current diagnosis are female
 More common in Caucasians
 Genetic (5-10% first degree relative)
 May take 10 years or more for diagnosis
◦ Average age of diagnosis is 50
◦ Confusing symptoms
◦ Delayed diagnosis or under diagnosed
 17% of Americans don’t know they have the disease
 Lifelong gluten free diet is the only treatment
◦ Less than 20ppm
Source: AGA Institute MedicalPosition Statement on the Diagnosisand Managementof Celiac
Disease.Gastroenterology. 2006; 131:1977-1980.
Source: Celiac Disease. NIH Publication No. 08-4269. September 2008.

Husby, S. & Murray, J. A. (2014) Diagnosing coeliac disease and the potential for serologicalmarkers
Nat. Rev. Gastroenterol.Hepatol. doi:10.1038/nrgastro.2014.162

 Abdominal bloating
 Abdominal pain
 Chronic diarrhea
 Vomiting
 Constipation
 Stool abnormalities
◦ Pale, foul-smelling, fatty
 Weight loss
 Irritability
 Malabsorption
 Fatigue
 Joint pain
 Muscle pain
 Osteopenia/Osteoporosis
 Iron-deficiency anemia
 Tingling in hands/feet
 Headaches
 Abnormal menses
◦ Infertility
◦ Recurrent miscarriage
 Canker sores
 Skin rash - itchy
◦ Dermatitis herpetiformis
◦ Dapsone treatment
 Cognitive impairment – brain fog
 Ataxia
 Automimmune diseases
◦ Thyroid disease
◦ Rheumatoid arthritis
◦ Type 1 diabetes
◦ Sjogren’s syndrome
◦ Addison’s disease
◦ SLE (lupus)
 Non Hodgkin’s Lymphoma
Disease.Gastroenterology. 2006; 131:1977-1980.
Source: Celiac Disease. NIH Publication No. 08-4269. September 2008.

Photo source: someecards.comand glutenfreedude.com

 Must be on a gluten diet for testing
 Blood tests
◦ IgA tissue trans-glutaminase antibodies (tTG)
 Most efficient single serologic test
◦ IgA/IgG deaminated gliadin peptide antibodies (DGP)
 Genetic testing
◦ Human leukocyte antigen (HLA) haplotypes
◦ DNA PCR
◦ HLA DQ2 (95%)/DQ8 (5%)
 No celiac if these are negative
 Intestinal biopsies
◦ Multiple biopsies
◦ Histological testing for villous atrophy
◦ Gold standard for diagnosis
 Skin biopsies
 Equivocal test results can occur
Disease.Gastroenterology. 2006; 131:1977-1980

 Consultation with a skilled dietitian
 Education about the disease
 Lifelong adherence to a gluten free diet
 Identification and treatment of nutritional deficiencies
 Access to an advocacy group
 Continuous long-term follow-up by a multidisciplinary
team
Source: NIH Consensus DevelopmentConferenceon Celiac Disease.

Photo source: helloglutenfree.com

 Is there a spectrum of disease?
 Non-celiac gluten sensitivity (NCGS)
◦ First described in 1980’s now “re-discovered”
 GI symptoms responsive to a gluten free diet
◦ May be able to titrate their gluten exposure to avoid symptoms
 Prevalence unclear
◦ Many people self-diagnose and start a gluten free diet without
medical consultation (not recommended)
◦ .5-6% based upon different studies
◦ More common in females
 Transitory or permanent?
Source: Fasano A, et al. Non-celiacgluten sensitivity: the new frontier of gluten related disorders. Nutrients. Oct 2013; 5(10): 3839-3853

 Diagnosis
◦ Difficult to distinguishfrom irritable bowel syndrome (IBS) or wheat allergy (WA)
◦ Lack of biomarkers for diagnosis
 First generation IgG AGA – 7.7%
 HLA DQ2/DQ8 – 50%
◦ Different histological changes on intestinal biopsy
 Present
◦ Younger age (case reports in children)
◦ Lack autoimmune or family history
◦ Constipation
 Less likely to be at risk
◦ Malabsorption
◦ Severe nutrient deficiencies
◦ Lymphoma
◦ No major complication if untreated
 Evolving spectrum
◦ Some more like celiac disease
◦ Some more like food allergy
◦ Is GMO wheat contributing?
◦ Possible relationship to autism and schizophrenia
◦ May be related to wheat amylase-trypsininhibitors
◦ May be related to low-fermentable, poorly absorbed, short chain carbohydrates
 Reduced FODMAPs (fermentableoligo-, di-, and mono-saccharidesand polyols) diet
 Fructans, galactans, fructose, and polyols
Source: Fasano A, et al. Non-celiacgluten sensitivity: the new frontier of gluten related disorders. Nutrients. Oct 2013; 5(10): 3839-3853.

 Nonceliac enteropathy (NCE)
◦ Can mimic celiac disease
◦ May cause villous atrophy
◦ Can respond to a gluten free diet

 Gibson et al- Australian study in 2011
◦ Double blinded, randomized, placebo controlled
◦ Small study
◦ Gluten containing diet caused GI distress in people w/o Celiac
Disease (CD)
 Biesiekierski/Gibson et al - repeat study in 2013
◦ Double blinded, placebo controlled, cross-over trial
◦ 37 patients gluten sensitivity (NCGS)
◦ FODMAPs reduction, low or high gluten, or whey (placebo)
challenge
◦ Improvement with FODMAPs reduction
◦ No specific response to gluten
◦ Nocebo effect – worsening of GI symptoms
Source: Biesiekierski/Gibson et al. “Is gluten a cause of gastrointestinalsymptoms in peoplewithout celiac
disease?” Curr Allergy Asthma Rep. 2013 Dec; 13(6):631-8.
Source: Biesiekierski/ Gibson et al. “No effects of gluten in patients with self-reported non-celiacgluten sensitivity
after dietary reduction of fermentable,poorlyabsorbed, short-chain carbohydrates.”Gastroenterology.2013 Aug;
145(2):320-8.e1-3.

 More research needed
◦ FODMAPS
◦ IBS
◦ Wheat Sensitivity
◦ Autism
◦ Schizophrenia
◦ Larger trials – double blinded prospective randomized controlled
trials
◦ Nocebo effect
◦ Other autoimmune syndromes or allergies
 Hashimoto’s, Sjogren’s, asthma
 Diagnosis of gluten sensitivity (NCGS)
◦ Need biomarker
◦ Transitory or permanent?
◦ True prevalence/incidence

Photo source: snapshotsat jasonlove.com

Photo source: someecards.comand glutendfreefun.blogspot.comand @glutenfreemomon Facebook

 Fads
◦ It is a good weight loss diet.
◦ Will make you “sick” or “fat”.
◦ GI symptoms will definitely occur.
◦ Healthy for you.
◦ Everyone is doing it.
◦ Ok to start a gluten free diet without a diagnosis.
 Facts
◦ People with celiac disease have a permanent lifelong intolerance and cannot
eat gluten.
◦ May cause an autoimmune response with GI symptoms.
◦ Some people may have an allergy or sensitivity.
◦ Gluten free diet may improve sensitivity symptoms.
◦ Medical information and evidence is evolving.
◦ Do not start a gluten free diet without a medical diagnosis or consultation.

 Americanceliac.org
 Celiac.com
 Celiac.org
 Celiaccentral.org
 Csaceliacs.org
 Eatright.org
 Gluten.net
 Glutenfreedrugs.com
 Healthyvilli.org
 NIH –
http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/
 Reallifewithceliacdisease.com

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@drjerath
@optimawhc
@optimavitality

Vandna Jerath, MD
Optima Women’s Healthcare
Optima Vitality MD
Sierra Medical Office Building
Parker Adventist Hospital Campus
9399 Crown Crest Blvd, Suite 450
Parker, CO 80138
303.805.1807 P | 303.595.5390 F
drjerath.com
optimawomenshealthcare.com
optimavitalitymd.com
Email - staff@optimawomenshealthcare.com
Slides – http://slideshare.net/VandnaJerathMD

PhotoSource: someecards.com

Gluten Free & Healthy Living: sort the fads from the facts

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