1. 1 Celiac Disease Chloe Bierbower Kelly Lonergan Brittany Pinkos Sarah Steinmetz

2. Learning Objectives  Be able to describe what Celiac Disease is  Be able to distinguish what foods should be avoided by someone with Celiac Disease  Be able to identify possible symptoms of CD or complications  Be able to design and prepare a diet free of food products containing gluten

3. What is Celiac Disease?  Autoimmune enteropathy triggered by the ingestion of gluten  Causes intestinal damage  Disease of both malabsorption and abnormal immune reaction to the protein gluten  Main groups of proteins  Gliadins, glutenins and other alcohol-soluble proteins found in grains ž Also known as celiac sprue, nontropical sprue and gluten- sensitivity enteropathy

4. What is Gluten?  Composite formed from several different proteins  Found most commonly in wheat and other related grains  Used in many processed foods as a thickener, binder, flavor enhancer and protein supplement

5. The Autoimmune Response  CD is the result of inappropriate T cell- mediation  Glutenin and gliadin (GLU) derived peptides act as antigens  Activates lamina propria to infiltrate CD4+ T lymphocytes from intestinal mucosa of SI  Leads to release of proinflammatory cytokines (in particular y-interferon) which cause profound tissue remodeling

6. 6  Specific CD4+ T-cell responses to GLU peptides are due to genes HLA-DQ2 and HLA- DQ8  Possible to have 2 HLA-DQ2 genes, 2 HLA-DQ8 genes or one of each  2 HLA-DQ2 genes results in the highest susceptibility for CD  Presence of these genes does not mean a patient will develop CD The Autoimmune Response cont.

7. Clinical Research Study  Results showed that both adult and young patients with CD can respond to diverse repertoire of GLU peptides  Regardless of which genes expressed  Inconclusive if a specific GLU protein triggers a specific immunological response

8. 8 Consequences of the autoimmune response  Immune reaction attacks and destroys small intestinal villi  Small intestinal villi aids in the absorption of nutrients  Without healthy villi the SI cannot extract and absorb nutrients from food  Regardless of the quantity of food consumed

9. Causes?  Unclear as of now  It is genetic  May be triggered by:  Surgery, pregnancy, childbirth, viral infection or severe emotional stress  Some gene mutations increase risk  More common in people with:  Type 1 diabetes, autoimmune thyroid disease, down syndrome, and microscopic colitis

10. What are the symptoms of CD?  Symptoms subdivided in typical or atypical forms  Symptoms vary with:  The age of the patient  Duration and extent of disease  Presence of extraintestinal pathology  Can be completely asymptomatic

11. 11 Symptoms of CD  Typical form (Typically in infants 6-18 months of age)  Chronic diarrhea  Failure to thrive  Abdominal distention  Anorexia  Muscle waisting

12. 12 Symptoms of CD cont.  Atypical form (more common in older children and adults)  Dermatitis herpetiformis  Iron-deficiency anemia  Short stature  Dentil enamel hypoplasia  Arthritis and arthralgia  Chronic hepatitis and hypertransaminaemia  Osteoporosis  Neurologic problems  Other GI problems 12

13. Symptoms in Adults  Fatigue  Bone or joint pain  Arthritis  Bone loss/osteoporosis  Depression or anxiety  Tingling/numbness in hands and feet  Missed menstrual periods  Infertility  Recurrent miscarriages  Canker sores  Dermatitis herpetiformis (itchy skin rash)  Seizures Experience different symptoms:

14. Why are symptoms varied?  Currently being studied  Could depend on length of time the person was breastfed  Age the person starting consuming gluten  Amount of gluten containing foods a person eats  Condition of the persons small intestine

15. Medical Conditions Associated with CD  Type 1 diabetes  Autoimmune atrophic gastritis  Autoimmune emocytopenic diseases  Autoimmune thyroid disease  Autoimmune liver disease  Rheumatoid arthritis  Addison’s disease  Sjogren’s syndrome  2-5% of patients with CD develop refractory CD, a serious complication associated with 50% risk of lymphoma development

16. Epidemiology of CD  Originally thought to be a rare childhood disease  Diagnosed at any age  CD may develop later in life  Over 2 million Americans have CD  Affects ~1 in every 133 Americans  Similar European statistic  Affects ~1 in every 22 Americans with genetic predisposition  Global prevalence of CD is increasing

17. How is Celiac disease diagnosed?  Difficult to diagnose  Often mistaken for other diseases  IBS, diverticulitis, intestinal infections  Histological and serological testing are essential  Look for abnormalities in SI  Presence of certain IgA autoantibodies  Positive diagnosis made when:  Typical SI histopathological abnormalities Hyperplastic villous atrophy  Clinical remission on a strict gluten-free diet with relief of symptoms within weeks

18. How is it treated?  Only known treatment is a Gluten-Free Diet  Complications Food presumed to be “gluten-free” but is contaminated Expensive Limited options Some medications and vitamins contain gluten  Supportive nutritional care with emphasis on iron and calcium

19. The Gluten-Free Diet  Avoid eating foods that contain:  Wheat, barley, rye, and certain soy products  Foods that contain these ingredients:  Cereals, pasta, and many processed foods  Important to talk to chefs, waiters and pharmacists

20. Foods to Avoid  Bulgar (several different wheat species)  Durum (species of wheat)  Farina (cereal food, cream of wheat)  Graham flour (whole wheat flour)  Semolina (purified wheat from durum wheat)  Spelt (ancient wheat species)  Triticale (wheat-rye hybrid)  Foods that contain these unless specified “gluten-free”

21. Most Common physical Complications  Malnutrition  Iron deficiency anemia  Loss of calcium and bone density  Lactose intolerance

22. 22 Psychological and Social Effects of CD  Study conducted in the UK  130 adults with CD described living with CD  Common responses:  Living with widespread ignorance  Social invisibility  Creating a celiac community  A changed identity  Grief and accepting the trade-off

23. 23 How is this relevant to the health industry?  As dietitians, we will come across people with CD who require treatment  We will also come across people with symptoms that suggest a diagnosis of CD is needed  The prevalence of this disease is increasing internationally so it’s important to be aware and knowledgeable

24. References (2011). Celiac Disease-Topic Overview. WebMD. Retrieved May 1, 2013, from http://www.webmd.com/digestive-disorders/ celiac-disease/celiac-disease-topic-overview. (2012). Celiac Disease. National Digestive Diseases Information Clearinghouse. Retrieved May 1, 2013, from http://digestive.niddk.nih.gov/ diseases/pubs/celiac/. Gianfrani, C., Auricchio, S., Troncone, R. (2005). Adaptive and innate immune responses in celiac disease. Immunology Letters, 99(2), 141- 145.

25. References Rose, C., Howard, R. (2013). Living with celiac disease: A grounded theory study. Journal of Human Nutrition and Dietetics. Vader, W., Kooy, Y., Van Veelen, P., De Ru, A., Harris, D., Benckhuijsen, W., Pena, S., Mearin, L., Drijfhout, J. W., Koning, F. (2002). The Gluten Response in Children With Celiac Disease is Directed Toward Multiple Gliain and Glutenin Peptides. Gastroenterology, 122, 1729-1737.

26. Questions?