Hot Topics in Nutrition for School Lunch: Celiac

1. Hot Topics in Nutrition for School Lunch: Celiac Carey O’Brien, MS RD LDN

2. Celiac Disease

3. What is it? • An Auto-Immune disease • There are many different auto-immune diseases: type 1 DM, Rheumatoid Arthritis, Lupus, Inflammatory Bowel Disease, etc. • It is a result of an over-active immune response to a protein in our foods (Gluten)

4. What is happening in the body? • The body see’s the protein (Gluten) and thinks it is not supposed to be there. • It “fights” against this protein with an antibody (our white blood cells) called Tissue Transglutaminase (tTG). • This tTG sends a message to the intestine to keep out the Gluten – which causes damage to the lining of the intestine.

5. Endoscopy Normal Duodenum Duodenal Scalloping

6. Histology Normal Duodenal Mucosa Villous Atrophy

7. How do you get Celiac? • Three things have to happen together: • You had to have eaten Gluten at some point in your life. • You have to carry the gene. • The Gene has to be turned on (like a light switch). But this light switch is broken and once it is turned on – it is never turned off. So you never out-grow Celiac.

8. Classic CD Abd pain, diarrhea, constipation Gas, distention Anorexia Poor wt gain/FTT in children. Unintentional wt loss in adults. Irritability/lethargy 2nd to MalNutrition Anemia, fatigue Vitamin def Osteopenia Apthous Ulcers Delayed puberty Infertility Dental enamel hypoplasia What are some of the Symptoms?

9. How is someone diagnosed? • All testing must be done while on Gluten containing diet • Bloodwork for antibodies (tTG) • If abnormal, then referral to GI specialist • GI specialist confirms with a scope

10. Management C Consultation with skilled dietitian E Education about disease L Lifelong adherence to GF diet I Identification of nutritional deficiencies A Access to a support group C Continuous long-term follow-up by multidisciplinary team

11. Dietitians and Reimbursement Issues • There is limited or no reimbursement for nutrition counseling for CD by insurance companies • Many patients/families will seek alternative sources (internet, support groups, family/friends, other health practitioners)…results in obtaining questionable information.

12. Gluten Free Diet • Attitudes are contagious!!! • Your perceptions of the Gluten free diet are likely to become your patients perceptions. We want to give our patients confidence, independence, and quality of life that will ultimately result in better compliance.

14. Barley Bran Bulgur Couscous Durum Emmer Einkorn Farro Farina Graham Kamut Orzo Rye Semolina Spelt (Dinkel) Triticale Wheat Label Reading – EliminateWHEAT, RYE, BARLEY

15. Amaranth Arrowroot Buckwheat Bean Flours Carageenan Cassava (Tapioca) Corn Flax Millet Nut Flours Potato Quinoa Rice Seed Flours Soy Sorghum Teff Label Reading - Safe

16. Oats • Currently the inclusion of oats in the GF diet remains an area of controversy. • Research regarding the safely of oats for people with celiac disease is still evolving • Gluten contamination of oat products • Oat prolamin (avenin) may trigger it’s own reaction

18. Food Allergen Labeling and Consumer Protection Act of 2004 • Has two parts • Part 1 – Effective Jan 2006 • Manufacturers must say in plain English if one of the 8 most common allergens is in the food. • The Top 8: WHEAT, milk, soy, egg, peanut, treenut, fish, shellfish. • Wheat is on this list, but rye and barley are not on this list. So if wheat is in that food as an ingredient, it MUST be listed.

19. Could be WHEAT Modified Food Starch Flour Cereal Products HVP Soy Sauce Flavoring Could be BARLEY Malt, Malt Flavoring, Malt Extract, Malt Syrup, Malto-Dextrin, Dextrin, Malt Vinegar Brown Rice Syrup Label Reading – Questionable Ingredients

20. FALCPA • Part 2 – Effective Jan 2008 • FDA has to come up with a definition for the Term: Gluten Free • Manufacturer’s can choose to label their foods as GF

21. GF Food Guide Pyramid • Fruits – fresh, frozen, canned • Vegetables – fresh, frozen, canned • Meats– fresh, read labels of processed • Nuts and Beans – fresh, canned, dried • Dairy – milk, cottage cheese, natural cheese, sour cream, cream cheese. Read labels on yogurts, ice creams, processed cheese, and pudding.

22. Food Guide Pyramid • Grains – • Rice, Corn, Potato in various forms. • Specialty foods required for cereals, breads, pasta, crackers, pizza, pancakes, waffles, cereal bars, communion hosts and baked goods. • Fats/Misc – Oils/Butter, Herbs/Spices. Read labels on salad dressings and marinades. GF gravies and cream sauces. • Sweets – Chocolates like M&M’s, sugar candies, jello, popsicles, and fruit snacks. (NOT Twizzlers)

23. Example of Meals • Breakfast: • GF cereal with milk, glass of juice • Eggs, GF Corn Tortilla, bacon, and milk • Lunch: • Rice, unbreaded chicken, cheese, sautéed fajita vegetables, fruit, milk • Snack: Corn chips and salsa • Dinner: • Meat, Potato or Rice, veg, milk. • Mexican • Snack: Ice Cream

25. Cross-contamination • Toaster • Food item containers • Clean counter tops, cooking equipment, and good handwashing technique • Cooking process

26. How much gluten is too much?? • Hischenhuber and colleagues reviewed a number of studies and concluded that the maximum tolerated daily intake of gluten is >10 mg and < 100 mg of gluten. • This equates to 1/50th to 1/500th of a slice of bread.

27. Cooking • Gluten: our structural protein in foods • Get to know your GF flours • Cooking properties, complementary flours, best product use. • Experiment…the kitchen can be a great science laboratory!

28. Web Resources • www.pittsburghceliacs.org • www.livingwithout.com • www.glutenfreeliving.com • www.glutenfreedrugs.com • Google: gluten+drugs+sholland • www.gluten.net • GIG publications downloaded free of charge • www.clanthompson.com • Drugs and gluten alerts/updates

29. Book Resources