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

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Gluten free for 2 ½ years

Community Health Seminar | Parker Adventist Hospital | 2/23/2016

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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.com and glutenfreedude.com

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


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


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 appeared in Practical Gastroenterology, 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 appeared in Practical Gastroenterology, 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

graham flour phosphated flour plain flour

self-rising flour semolina white flour

Processed Foods that May Contain Wheat, Barley, or Rye*

bouillon cubes brown rice syrup candy chips/potato chips cold cuts, hot dogs, salami, sausage communion wafers

French fries gravy imitation fish matzo rice mixes sauces

seasoned tortilla chips self-basting turkey soups soy sauce vegetables in 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 Medical Position Statement on the Diagnosis and Management of 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 serological markers 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

Source: AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006; 131:1977-1980. Source: Celiac Disease. NIH Publication No. 08-4269. September 2008.


Photo source: someecards.com and 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

Source: AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac 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 Development Conference on 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-celiac gluten sensitivity: the new frontier of gluten related disorders. Nutrients. Oct 2013; 5(10): 3839-3853


Diagnosis ◦ Difficult to distinguish from 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-trypsin inhibitors ◦ May be related to low-fermentable, poorly absorbed, short chain carbohydrates

Reduced FODMAPs (fermentable oligo-, di-, and mono-saccharides and polyols) diet

Fructans, galactans, fructose, and polyols

Source: Fasano A, et al. Non-celiac gluten 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 gastrointestinal symptoms in people without 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-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, 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: snapshots at jasonlove.com


Photo source: someecards.com and glutendfreefun.blogspot.com and @glutenfreemom on 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


http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/

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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 - [email protected] Slides – http://slideshare.net/VandnaJerathMD


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gluten free & healthy living: sort the fads from the facts

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