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. 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 MucosaVillous Atrophy

7. How do you get Celiac?  Three things have to happen together: 1. You had to have eaten Gluten at some point in your life. 2. You have to carry the gene. 3. 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. What are some of the Symptoms? Classic CD  Abd pain, diarrhea, constipation  Gas, distention  Anorexia  Poor wt gain/FTT in children. Unintentional wt loss in adults.  Irritability/lethargy 2 nd to MalNutrition  Anemia, fatigue  Vitamin def  Osteopenia  Apthous Ulcers  Delayed puberty  Infertility  Dental enamel hypoplasia

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

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

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 Gluten contamination of oat products Oat prolamin (avenin) may trigger it’s own reaction 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. 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. 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. 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. Label Reading – Questionable Ingredients 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

20. FALCPA  Part 2 – Effective Jan 2008 FDA has to come up with a definition for the Term: Gluten Free FDA has to come up with a definition for the Term: Gluten Free Manufacturer’s can choose to label their foods as GF 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. Rice, Corn, Potato in various forms. Specialty foods required for cereals, breads, pasta, crackers, pizza, pancakes, waffles, cereal bars, communion hosts and baked goods. 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 GF cereal with milk, glass of juice Eggs, GF Corn Tortilla, bacon, and milk Eggs, GF Corn Tortilla, bacon, and milk  Lunch: Rice, unbreaded chicken, cheese, sautéed fajita vegetables, fruit, milk Rice, unbreaded chicken, cheese, sautéed fajita vegetables, fruit, milk  Snack: Corn chips and salsa  Dinner: Meat, Potato or Rice, veg, milk. Meat, Potato or Rice, veg, milk. Mexican 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 10 mg and < 100 mg of gluten.  This equates to 1/50 th to 1/500 th 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. Cooking properties, complementary flours, best product use.  Experiment…the kitchen can be a great science laboratory!

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

29. Book Resources