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DOS CME Course 2011 1 Oxtober 2010 1 Confidential
Nutrition Matters: An update on Human Nutrition
Lynda N. Newman, MSN, RN, ACNS-BC, CNN
Clinical Nurse Specialist Center for Human Nutrition Digestive Diseases Institute Cleveland Clinic
© Cleveland Clinic 2014 DOS CME Course 2014 1
• After attending this presentation, the participant will be able to:
1) Distinguish between food allergy and food intolerance 2) List two dietary interventions to recommend to symptomatic
patients
Objectives
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Chief Complaint:
http://advancedallergytreatment.com
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Adverse Food Reaction
Immune Non-immune
IgE (Oral Allergy Syn.
Hives Anaphylaxis)
Non-IgE (Food-Protein
induced Enterocolitis Syn.,
Celiac)
Mixed (Eosinophilic Esophagitis)
Cell
(Allergic contact Dermatitis)
Pharmacological (Tyramine)
Metabolic (Lactose
Intolerance)
Other (Mechanical, physiological)
Toxic (e.g.Scromboid Clostidium, etc.)
Modified from Boyce JA, et al. JACI 2010;126:1105
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• Affects all people alike
• Seafood – Scromboid poisoning (fresh tuna & mackerel) – Ciguatera poising (grouper, snapper) – Saxitoxin (shellfish)
• Other food poisoning – Clostridium botulinum (improperly canned foods) – Staphylococcus aureus (pre-cooked and processed foods) – Salmonella (poultry)
• Fungal toxins: – Aflatoxin (peanut butter, cooking oils) – Trichothecanes (cereals) – Ergot (rye and other grains)
Definitions: Toxic Reactions
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• Non-toxic – Unique reactions – Only some people are affected
• Food Allergy – Adverse health effect – Specific immune response – Reproducible on exposure to a given food
• Food intolerance – Adverse health effect – NOT immune mediated – Example: Lactose intolerance
– Ingestion causes cramps, diarrhea and gas
Definitions
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• Immune response – Immune OVER-REACTION to offending protein – Antibody response as if to HOSTILE invader
• Physical response – Swelling of face, eyes and tongue or throat – Difficulty breathing – Skin irritation
–Eczema or Hives – Nausea and vomiting
True Food Allergy
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Think EpiPen
Or
Auvi-Q
• Some children outgrow food allergies – But allergies to peanuts and nuts seldom go away!
Severe Food Allergy Reaction
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• Rate of perceived food allergy = 20%
• True food allergy – By double-blind, placebo-controlled food challenge = 1.4%
• Industrialized nations – 1 in 20 young children – 1 in 50 adults
• More common in infants and children – Most outgrow their hypersensitivity
Food Allergy Facts
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• Can vary from acute uticaria to FATAL ANAPHYLAXIS
• Most food allergies are caused by just a few major food allergens*
– Milk - Eggs – Soy - Wheat – Fish - Peanuts (legume, not a true nut) – Shellfish - Tree nuts (Walnuts, etc)
– *New law will require these allergens to be clearly labeled to have
any of these and clear guidelines for labeling foods as “Gluten-free”
Food Allergy Symptoms
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• Generalized reaction – Anaphylaxis
• Respiratory reaction – Asthma – Rhinoconjunctivitis – Laryngeal edema
• Cutaneous reactions – Dermatitis herpetiformis – Urticarial angioedema – Atopic dermatitis
Disorders Related to Food Allergy • Specific GI Syndromes
– Oral allergy syndrome – GI anaphylaxis – Allergic eosinophilic gastroenteritis – Food-protein induced – Proctocolitis – Enteropathy – Enterocolitis syndrome – Celiac disease
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• 65% of children lose reactivity to wheat by age 12
• Can affect up to 1% children
• Systemic: Anaphylaxis – Wheat-dependent exercise-induce anaphylaxis (WDEIA) – IgE to omega-5-gliadin
Wheat Allergy and Anaphylaxis
Keet CA et al. Ann Allergy Asthma Immunol 2009;102:410 Inomata N. Curr Opin Allergy Clin Immunol 2009;9:238
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• Lactose is hydrolyzed by – Intestinal lactase to glucose and galactose – Microvillus membrane of the intestinal adsorptive cells
• Lactase production can be reduced by – Mucosal injury – Reduced genetic expression of the enzyme lactase-phlorizin
hydrolase
Lactose Intolerance
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• Lactose progresses to the colon
• Converts to – Short-chain fatty acids (SCFA) – Hydrogen gas – By bacterial flora – Producing acetate, butyrate, and propionate – SCFAs are absorbed for energy
What Happens When Lactose Is Not Absorbed In The Small Intestines?
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• Hydrogen gas!!! – Cramps – Bloating – Pain – Flatulence
• Basis of Hydrogen Breath Test
What’s Left?
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• Developmental
• Congenital
• Secondary: – Celiac disease – Bacterial overgrowth – Possibly Crohn’s disease
Causes of Lactose Intolerance
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Common multi-system autoimmune disorder – Genetic – Environmental – Immunologic components
What is Celiac Disease?
Wikipedia.com/celiac
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• What types of people? – Adults > Children – Females > Males – Caucasians 1:133 people
–Blacks and Asians can develop Celiac disease
• Age – Any from children to elderly
• People with immune disorders
• Family members of Celiacs
• NOT just a kid’s disease anymore!
Who Gets Celiac Disease?
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• Autoimmune
• Genetically susceptible individuals – DQ2 and/or DQ8 positive Human Leukocyte Antigen (HLA)
haplotype is necessary – But not sufficient
• Unique because – Both the environmental trigger (gluten) and the auto-antigen
(tissue Transglutaminase) are known – Elimination of environmental trigger leads to a complete resolution
of the disease
Celiac Defined
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The Celiac Iceberg
Genetic susceptibility:
DQ2, DQ8
Healthy individual
Latent Celiac Disease
Silent Celiac
Atypical
Classic Celiac Disease Histologic Changes
Normal Mucosa
Abnormal Serology
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Gluten
Gluten-free diet
Normal Small Bowel Celiac Disease
Cleveland Clinic Medical Art & Photography
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• Confirm diagnosis before treating – Celiac Disease diagnosis mandates a strict gluten-free diet for life
–Following the diet is not easy – Quality of life (QOL) implications
• Failure to treat – Potential long term adverse health consequences – Morbidity and mortality
Diagnosic Principles
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Serum Tests for Diagnosis of Celiac Disease
Test Sensitivity
(Range) Risk of False Pos
Specificity (Range)
Risk of False Neg Comments
IgA anti tTG ATB
>95.0 (73.9-100)
>95.0 (77.8-100) First level screen
IgG anti-tTG ATB
Widely variable (12.6-99.3)
Widely variable (86.3-100)
Useful with IgA deficiency
IgA anti-endomysial ATB
>90 .0 (82.6-100)
>90 .0 (94.7-100)
Useful when Dx is uncertain
IgG DGP >90.0 (80.1-98.6)
>90.0 (806.0-96.9)
Useful with IgA deficiency and young children
HLA- DQ2 or HLA- DQ8
91.0 (81.6-97)
54.0 (12.0-68.0)
Highly negatively predictive
adapted from: Fasano A, Catassi C. N Engl J Med 2012;367:2419-2426
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Clinical and Pathogenic Differences Among Celiac Disease, Gluten Sensitivity and Wheat Allergy
Variable Celiac Disease Gluten Sensitivity Wheat Allergy
Exposure to symptom interval Weeks to Years Hours to Days Minutes to Hours
Pathogenesis Autoimmunity (innate and adaptive)
Possibly innate immunity
Allergic immune response
HLA Restricted to HLA-DQ2 or HLA DQ8
(pos. in 97%)
Could be pos . HLA-DQ2 and HLA
DQ8 positive (50% have both)
Similar to gen. population. Could be neither, one or
both 35-40%
Auto-antibodies Almost always present Always absent Always absent
adapted from: Fasano A, Catassi C. N Engl J Med 2012;367:2419-2426
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Clinical and Pathogenic Differences Among Celiac Disease, Gluten Sensitivity and Wheat Allergy
Variable Celiac Disease Gluten Sensitivity Wheat Allergy
Enteropathy Almost always present Always absent Always absent
Symptoms
Intestinal and extra-intestinal:
Symptoms same as gluten sensitivity
and Wheat allergy
Intestinal and extra-intestinal:
Symptoms same as Celiac disease and
Wheat allergy
Intestinal & extra-intestinal:
Symptoms same as Celiac disease and
gluten sensitivity
Complications
Co-existing conditions Long term
complications
Absence of co-existing conditions
Long term complications
Absence of co-existing conditions
Short term complications
e.g. Anaphylaxis
adapted from: Fasano A, Catassi C. N Engl J Med 2012;367:2419-2426
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• Gluten sensitivity due to Celiac Disease (CD) – Genetically pre-disposed person – Chronic small intestinal immune mediated enteropathy – Precipitated by exposure to dietary gluten
• Non-Celiac Gluten Sensitivity (NCGS) – Celiac disease has been ruled out – One or more immunological, morphological and/or symptomatic
alterations triggered by gluten ingestion
What is Gluten Sensitivity?
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Proposed Algorithm for the Differential Diagnosis of Gluten-Related Disorders.
Fasano A, Catassi C. N Engl J Med 2012;367:2419-2426 DOS CME Course 2014 30
Based on : Alaedini A, Green PHR. Ann Intern Med 2005;142:289-298
• Endocrine – Autoimmune thyroid disorders – Type I Diabetes – Addison’s disease – Alopecia areata – Reproductive disorders
• Cardiac – Autoimmune myocarditis – Idiopathic dilated cardiomyopathy
• Hepatic – Autoimmune cholangitis – Autoimmune hepatitis – Primary biliary cirrhosis
Disorders Associated with Celiac Disease • Neurologic
– Epilepsy – Cerebellar ataxia – Migraine – Neuropathy
• Other – Anemia – Dental enamel defects – Down syndrome – Juvenile chronic arthritis – Osteoporosis – Selective IgA deficiency – Sjogren’s syndrome
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• Affects 10-20% of Celiac pts.
• Pruritic, chronic skin disease characterized by – Symmetrical papulo-vesicular lesions – Presence of granular deposits of IgA
in dermal papillae
• Rx – Gluten-free diet – With / without Dapsone
Dermatitis Herpetiformis
dermatology atlas online
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• Endoscopic features of villous atrophy
• Reduced number of folds
• Scalloping of folds
• Mucosal grooves
• Mosaic appearance
• Atrophic appearance – Biopsy is the “gold standard”
GI Endoscopy
Donald Kirby, MD Cleveland Clinic
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• Confocal endomicroscopy – Permits in vivo magnification up to 1000 fold – Sensitivity 94% – Specificity 92% – Also sensitive in seeing changes with GFD
• Video capsule – Has shown 1/3rd of Celiac patients have mucosal changes
beyond the duodenum – Compared to biopsy – Sensitivity 88% (true positives) – Specificity 91% (true negatives) – positive predictive value 97% – negative predictive value 71%
GI Methods of Diagnosis
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Murray J, et al. Clin Gastroenterol Hepatol 2008;6:186-193
Distribution of Villous Atrophy seen in Wireless Capsule Endoscopy
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Untreated Celiac Disease Gluten Free Diet x6 Months
Biopsies Are Important!
Cleveland Clinic Medical Art & Photography
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• Therapy of choice – Vitamin deficiencies resolve – Risk of autoimmune mediated diseases and Celiac Disease – Associated malignancies is reduced
• Even fully compliant 7-30% may not go into full remission – ~5% refractory disease
Gluten Free Diet
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• Several meanings misinformation
• Bakers think gluten is “sticky” part of ANY grain
• Includes corn and rice – These are safe for people with celiac disease
• Better to inquire whether food is Gluten Free or has any ingredients derived from wheat, barley, rye
Gluten
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• High fat diet
• Low fiber diet
• Low carbohydrate diet
• Diet low in – Iron, folate, niacin, vitamin B12, calcium, phosphorus, zinc
• Lactose intolerance
Potential Nutritional Issues
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• Wheat flour is fortified with vitamins, minerals and iron
• Gluten Free grains are made from refined flours/starches – That are not enriched
• Deficiencies – Calcium, vitamin B complex, iron, vitamin D
• Low fiber intake
Potential Deficiencies
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• Provided by registered dietitian is strongly recommended
• Consultation with a registered dietitian – Part of a team-based approach – Results in improved self-management
ADA Pocket Guide to Gluten-Free Strategies
Medical Nutrition Therapy
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• Essential to effectively determine nutrition diagnoses and plan the intervention – Food and nutrition intake – Medication and supplement use – Readiness to change – Behavior (social network)
ADA Pocket Guide to Gluten-Free Strategies
Nutrition Assessment
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• Choose GF whole grains and products made from them – Brown rice, millet, buckwheat, whole corn
• When choosing refined grain foods, (breads, cereals, pastas) select products that are in enriched or fortified
Nutrition Recommendations
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• Grain foods = > 2 g fiber/serving
• Avoid products with Trans fat
• Choose products with least amount of total and saturated fat when comparing similar products
Nutrition Recommendations
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– In the field prior to harvesting – During transportation off grains and plant foods to be processed – At the grain-processing plant – At the food manufacturing plant – In the home, restaurant…..
Cross Contamination
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• Use separate jars of peanut butter, jelly, butter, mayo to avoid crumbs in jar
• Clean utensils thoroughly before cutting gluten free foods
• Use separate fryers or clean oil
• Separate toaster and dishes
Avoid Cross-Contamination
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• Research on individuals with celiac disease found including oats
– Not contaminated with wheat, barley, or rye – At intake levels of ~50 grams of dry oats per day – Is generally safe and – Improves compliance with the GF diet
Oats
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• All foods that are GF are not necessarily “healthy”
• Manufacturers make it very easy for shoppers to find GF foods and market them as such
• Usually found in “health food” section
• Ever read the food labels?
Gluten-Free Stamp
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• Labeling of allergens is not mandatory – Estimated 80-90% voluntary compliance
• If product label has “Contains” statement or other allergen labeling – Manufacturer is voluntarily complying with allergen labeling
Label Reading
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• USDA mandates that all foods are to be listed by their common/usual name – Malt, starch, modified food starch, dextrin
• Protein ingredients must be listed by common/usual name and cannot be hidden under collective names – Natural flavorings – “May contain” statements are also voluntary
Ingredient Labels
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• Long ingredient lists of names you do not recognize – Not a good sign
• Look at sugar content
• Look at sodium content
• Highly processed = added fat, added sugar – High calorie
Label Reading
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• Dextrin – Unless GF ingredient listed
• Modified food starch – Unless GF grain is listed
• Starch – Unless GF grain is listed
Questionable Ingredients
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• Avoid the following unless GF can be confirmed – Brown rice syrup – Hydrolyzed Vegetable Protein (HVP) – Hydrolyzed Textured Protein (HTP) – Textured Vegetable Protein (TVP) – Rice malt – Seasonings – Soy sauce – Modified food starch
Questionable Ingredients
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Hidden Gluten Sources
• Broth
• Energy bars
• Imitation bacon
• Vitamins/minerals, meds
• Communion wafers
• Processed meats – Deli, bolgona – Hot dogs – Lunch meat
• Nutritional supplements
• Sauces, gravies
• Pastas
• Marinades
• Roux, thickeners
• Stuffing, dressing
• Imitation seafood
• Breading
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• “If in doubt, leave it out!”
• Just Say NO to: –Bites –Licks –Tastes
Better To Be Safe Than Sorry
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• Call / write manufacturer directly
• Request written info re: OTC and Rx
• Ask about fillers, tablet coatings or capsules
• Brand name vs generic equivalents – Same ingredients? – Still GF?
• Glutenfreedrugs.com
Medications
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• Most likely – Starch (unspecified) – Dusting powder – Pregelatinized starch – Flour (unspecified)
• Less likely – Sodium starch glycolate (corn) – Caramel coloring
• Least likely – Maltodextrin (corn)
Inactive Ingredients in Medications
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Alcohol
• Allowed – Wines – Distilled beverages
–Gin, rum, vodka, whiskey – Pure liqueurs – GF beer
• Avoid – Beer – Ales – Lagers – Wine coolers
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• Choose restaurants with wide variety of choices
• Options: Mexican, Indian, Thai, Japanese
• Check ahead of time for restaurants indicating a GF menu
Dining Out
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• Fried foods need to be in different oil
• Hamburgers = no fillers / never touched the bun
• Request grill be wiped down/washed – Before food is cooked
• Emphasize importance of keeping utensils clean and separate from other foods
• Suggest contacting restaurant ahead of time
Tips to Keep in Mind
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• Healthy options for all!
• Milk
• Cheese
• Fruit
• Vegetables
• Fresh meats
• Fish
• Poultry
• Nuts
• Rice
Naturally Gluten Free
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• Portion Control
– Used to eating larger portions to maintain weight
– With healing intestines the larger amounts are unnecessary
Weight Management Considerations
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• GF diet education – Must include discussions related to weight gain
• These patients used to eat whatever they wanted and did not gain weight
• Patients should be made aware of this and provided information as to why this is healthy
• Goals – Want CD patients to follow GF diet – Not be “afraid” of weight gain
Weight Management Considerations
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• Promotes weight loss – ONLY if person has been overeating Carbohydrates
• Promotes weight gain – Easily
• Gluten Free diet healthy vs Gluten Free diet made up of Gluten Free processed high Carb -type foods
• Some with gluten intolerance benefit from decreasing or avoiding gluten – Case by case basis
Bottom Line
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• Placebo response in Irritable Bowel Syndrome (IBS) up to 70% – Gluten (increased prolamines) is hard to digest – Increases stool volume
• GFD often eliminates other dietary factors – Potentially other mechanisms explain the benefit – Sensitivity to factors other than gluten or even grains
Is Dietary Response to A Gluten Free Diet (GFD) Diagnostic of Celiac Disease?
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• Positive Predictive Value of symptom improvement after gluten withdrawal for Celiac Disease – only 36% in one study (1)
• Celiac Disease patients have Increased Irritable Bowel Syndrome (IBS) -type symptoms compared with controls (2)
• Irritable Bowel Syndrome (IBS) patients are more likely to demonstrate Non-Celiac gluten sensitivity than controls (2)
Is Dietary Response to A Gluten Free Diet (GFD) Diagnostic of Celiac Disease?
1-Campanella J, et al. Scand J Gastroenterol 2008;43:1311 2-Sainsburg A , et al. Clin Gastroenterol Hepatol 2013:11:359
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• RCT in 45 subjects with IBS-D comparing – 4 weeks of Gluten Free Diet (GFD) against – 4 weeks of Gluten Containing Diet (GCD)
• Stratified by HLA DQ 2/8 status
• Assessed: – BMs – Gut transit – Permeability – Histology
Controlled Trial of Gluten Free Diet in Irritable Bowel Syndrome with Diarrhea (IBS-D)
Vazquez-Roque MI, et al. Gastroenterology 2013;144:903
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• Results – More BMs in GCD,
–Especially if HLA DQ2/8+ – GFD benefitted IBS-D patients
–Stool frequency, permeability –Especially if HLA DQ2/8+
• No effect on transit or histology
Controlled Trial of Gluten Free Diet in Irritable Bowel Syndrome with Diarrhea (IBS-D)
Vazquez-Roque MI, et al. Gastroenterology 2013;144:903
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• Type 1 – Normal intraepithelial lymphocyte phenotype – Rx – steroids, et al.
• Type 2 – Clonal expansion of aberrant intraepithelial lymphocyte population – Bad prognosis – steroid refractory – Increased risk of lymphoma
Refractory Celiac Disease
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Therapeutic Agent Mechanism of action
Genetically modified gluten
Decreases gluten exposure by transamidation of gliadin
Zonulin inhibitor Decreases zonulin secretion and inhibits intestinal permeability - Phase III trials
Therapeutic vaccine
Creates immune tolerance to gluten fragments and desensitizes celiac disease patients to the toxic effects of gluten DQ-2 positive patients only -
Probiotics Detoxify gliadin, promote intestinal healing
Tissue transglutaminase
inhibitors
Stop tissue transglutaminases from modifying gluten fragments, a process that otherwise triggers the immune response
Bakshi A, et al. Gastroenterology & Hepatology. 2012;8:582-588
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• Gluten-free diet
• Tincture of time
“Thy food shall be thy medicine” - Hippocrates
Celiac Disease Treatment
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• 54 yo man with known Dermatitis Herpetiformis (DH) – HLA DQ8 positive – On a strict Gluten Free Diet that has put him
–In remission for his Celiac Disease – In remission DH
• He asks you how best to see if his 18 year old college- bound daughter should be Gluten free at college 1. Tell her best to be Gluten Free – no testing 2. Obtain endoscopy as soon as possible 3. Obtain HLA testing 4. Obtain IgA and Tissue Transglutaminase IgA and IgG
Case 1
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• Obtain HLA testing will have the best NEGATIVE predictive value
• Daughter WAS Negative for HLA DQ2 and DQ8
Case 1
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Unidentified GI Symptoms: FODMAP Diet
Fermentable, Oligo-Di, Mono-saccharides and Polyols
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• Fermentable
• Oligo-
• Di- and
• Mono-saccharides And
• Polyols
• Three common properties – Poorly absorbed by the small intestine – Small, osmotically active molecules – Rapidly fermented by bacteria
FODMAPS
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• Branched fructose polymers – Oligosaccharide and polysaccharide (FOS)
• Inulin – Subgroup of fructans
• Polyols – Sorbitol – Xylitol – Mannitol – Malitol
Fructans
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• Small intestines do not have enzyme to break up fructose-fructose bonds
• Cannot be broken down to monosaccharides
• Cannot be transported across epithelium leading to malabsorption
• = Laxative effect
• Major sources of fructans – Wheat – Artichokes
Fructans
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• Sorbitol = most common
• Polyol effects worsen when consumed with fructose
• Foods containing polyols: apples, pears, apricots, peaches, plums, cherries, nectarins
• Sugar-free foods w/ artificial sweeteners
Polyols
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• Bloating, abdominal distention, discomfort, pain, altered bowel habits are categorized as “functional” gut symptoms
• Related to the enteric nervous system and the gut – Usually not abnormality in structure
Functional Gut Symptoms
Above is the image at: lostcheese.teacherarnold.com/.../upset-stomach
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Carbohydrates Considered FODMAPS
www.GInutrition.virginia.edu
Fructans and Galactans Polyols
Fructose Sorbitol
Lactose Mannitol
Fructooligosaccharides Xylitol
Galactooligosaccharides Malitol
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• All FODMAPS = Osmotic and fermentative
• Minimize distention – Small bowel and proximal large bowel
• Studies have shown that those provided with low FODMAP diet instruction adhere to it extremely well
Principles of Low FODMAP Diet
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Suggested Theory For Relationship Between Functional Gut Symptoms and FODMAPS
Practical Gastroenterology • August 2007
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• Identify typical eating practices of the patient to distinguish types of FODMAPS consumed regularly – Food records – Direct questioning – FODMAP checklist –
• Explain the scientific basis of FODMAPS – Malabsorption and fermentation
Key to Success
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• Avoid foods containing free fructose or lactose – Unless negative breath tests)
• Fructose : Glucose ratio balanced
• Consume glucose-containing foods to balance
• Limit dietary fructose load at one meal
• Avoid foods high in fructans and galactans
Low FODMAP Diet Strategies
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Sample (Fruits)
Intestine Friendly Food to Avoid if FODMAP Intolerant
Questionable Foods/Foods to
Limit
Bananas, blackberries, blueberry, grape, grapefruit, honeydew, kiwifruit, lemons,
limes, mandarin orange, melons, oranges, papaya, passion fruit, pineapples,
raspberries, rhubarb, strawberries, tangelos
Apples, apple cider, apple juice, applesauce, apricots,
cherries, dates, grapes, lychee, mango, peaches, pears, pear juice, plums,
prunes, watermelon
Other fruit juices or drinks, sugar-free jam/jelly, dried fruit, canned fruit in heavy
syrup, other fruits
www.GInutrition.virginia.edu
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Sample (Vegetables)
Intestine Friendly Food to Avoid if FODMAP Intolerant
Questionable Foods/Foods to
Limit
Bamboo shoots, bok choy, carrots, cauliflower, celery, cucumber, eggplant, green beans, green peppers, leafy greens, parsnip, pumpkin, spinach, sweet potatoes, white potatoes, other root
vegetables
Artichokes, asparagus, some beans (baked beans, chickpeas, kidney beans, lentils) beetroot, broccoli,
brussels sprouts, cabbage, cauliflower, fennel, garlic,
sugar snap peas, leeks, soy products, okra, onions, peas,
shallots
Avocado, corn, mushrooms, tomatoes, other beans
www.GInutrition.virginia.edu
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Sample (misc.)
Intestine Friendly Food to Avoid if FODMAP Intolerant
Questionable Foods/Foods to
Limit • All meats
• All fats
• Yogurt and hard cheeses
• All eggs
• Aspartame(Equal®; Nutrasweet®)
• Saccharin (Sweet `n Low®)
• Sucrose (table sugar)
• Glucose
• Honey
• Flavorings with fructose or sorbitol
• Desserts (icecream, candy, cookies, bars, popsicles with fructose or sorbitol)
• Cereal or other processed foods containing fructose
• Sherry and port wine
• Sorbitol, mannitol, xylitol, maltitol, and isomalt used in sugar-free gum/candies/mints
• Limit products with HFCS if symptoms still continue
• If you experience symptoms with lactose, try limiting milk, cottage cheese, and other lactose-containing foods
• (see lactose intolerant diet ed mat)
www.GInutrition.virginia.edu
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• Strict low FODMAP diet for 6-8 weeks
• Keep food diary/symptom diary
• Examining accumulated intake over several days is essential to gauge how strict the patient will need to be
Recommendations
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• Diet compliance
• Correct deficiencies
• Modify intake of resistant starch and soluble and insoluble fiber
• Food chemicals
• Caffeine
• Fat intake
• Meal size
• Regularity
Symptoms Still Present…
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• Not a cure
• Restriction of foods with prebiotic effects – Unfavorable for large bowel health
• Decrease in fiber intake
• Watch out for medications
Limitations to Diet
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• Paleolithic Diet – Stone age or Hunter-gatherer diet
• Centered on – Fish – Grass-fed pasture raised meats – Eggs – Vegetables – Fruit – Fungi – Roots
Other Interesting Diets
• Excludes – Grains – Legumes – Dairy products – Potatoes – Refined salt – Refined sugar – Processed oils
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• Advantages – Largely free of diseases of affluence
• Disadvantages – Questionable science – May be low in fiber and calcium
Paleolithic Diet Stone age or Hunter-gatherer diet
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• Purports to reduce the symptoms of – Irritable Bowel Syndrome – Inflammatory Bowel Disease
–Crohn’s Disease –Ulcerative Colitis
– Celiac Disease – “Leaky Gut” – Autism
Specific Carbohydrate Diet (SCD)
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• Allowed – Meats Lean meats, game meats, eggs, poultry – Vegetables Most fresh or frozen – Fruits Most fresh or frozen – Dairy Yogurt, aged cow or goat cheese – Nuts and Legumes
• Not Allowed – Any cereals or grains – Meats Processed or cured – Any canned fruits or vegetables – Starchy vegetables and legumes
Specific Carbohydrate Diet (SCD)
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• 28 year old woman
• Bloating, diarrhea, gas, feeling of fullness
• Fructose breath hydrogen test – negative
• Negative for Celiac Disease
• Requesting Gluten Free diet education
• Also interested in weight loss
Case 1
DOS CME Course 2014 103
• Newly diagnosed Celiac Disease
• No weight issues –
• Diet recall per patient – I can eat whatever looks good
• I don’t feel any worse when I eat Gluten Free – Do I have to do this diet forever?
Case 2
DOS CME Course 2014 104
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