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Click on Alessio Fasano MD Webinar Description Page 11/5/2018 COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS November 5, 2018 Gluten-Related Disorders: How to Distinguish Facts from Fantasies Moderator: Lisa Diewald MS, RD, LDN Program Manager MacDonald Center for Obesity Prevention and Education Nursing Education Continuing Education Programming Research FINDING SLIDES FOR TODAY’S WEBINAR www.villanova.edu/COPE Click on Alessio Fasano MD webinar description page DID YOU USE YOUR PHONE TO ACCESS THE WEBINAR? If you are calling in today rather than using your computer to log on, and need CE credit, please email [email protected] and provide your name so we can send your certificate. 1 11/5/2018 OBJECTIVES 1.Recognize the differences between celiac disease, non-celiac gluten sensitivity and wheat allergy. 2.Discuss the epidemiology of celiac disease and why prevalence is increasing 3.Identify the role of the gut microbiome and intestinal permeability in autoimmune disease CE DETAILS • Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation • Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration • The American College of Sports Medicine’s Professional Education Committee certifies that Villanova University College of Nursing Continuing Education, Center for Obesity Prevention and Education (COPE) meets the criteria for official ACSM Approved Provider status (10/2018-9/2021). Providership #698849 CE CREDITS • This webinar awards 1 contact hour for nurses and 1 CPEU for dietitians • Suggested CDR Learning Need Codes: 2000, 5110, 5220 and 6000 • Level 2 • CDR Performance Indicators: 8.1.2, 8.1.5, 8.3.1, 8.3.6 2 11/5/2018 GLUTEN AND GLUTEN-RELATED DISORDERS: HOW TO DISTINGUISH FACTS FROM FANTASIES Alessio Fasano, MD Chief of Pediatric Gastroenterology and Nutrition Mass General Hospital for Children Professor of Pediatrics Harvard Medical School DISCLOSURE The planners of this program have no conflicts of interest to disclose. Any presenter conflict of interest was resolved prior to the planning of this program. Any additional disclosure information will be provided to participants during the live activity. The Nurse Planner has reviewed the presentation and determined that it is evidence-based, balanced and unbiased Accredited status does not imply endorsement by Villanova University, COPE or the American Nurses Credentialing Center of any commercial products or medical/nutrition advice displayed in conjunction with an activity. Celiac Disease And Other Gluten Related Disorders: How To Distinguish Facts From Fantasies Alessio Fasano, M.D. W. Allan Walker Chair in Pediatric Gastroenterology and Nutrition Professor of Pediatrics Harvard Medical School Mucosal Biology and Immunology Research Center And Center for Celiac Research And Treatment Massachusetts General Hospital for Children 3 11/5/2018 Conflict of Interest Disclosure Alessio Fasano, MD I disclose the following financial relationships with commercial entities that produce health care related products or services relevant to the content I am planning, developing, or presenting: Company Relationship Content Area Alba Therapeutics Stock Holder Alternative treatments to gluten free diet for celiac patients Inova Diagnostics Consultant Innovate Consultant Biopharmaceuticals, Inc. Mead Johnson Nutrition Speaking Agreement The Controversy On Who Should Be On A GFD Only People With Celiac Disease Everybody The Source Supporting GFD For Everybody 4 11/5/2018 The Epidemics Of Gluten Related Disorders - Quality of gluten: GE grains - Quantity of gluten - Gluten cannot be digested The Epidemics Of Gluten Related Disorders - Quality of gluten: GE grains - Quantity of gluten - Gluten cannot be digested Kasarda D. J Agric Food Chem. 2013;61: 1155–1159 5 11/5/2018 Kasarda D. J Agric Food Chem. 2013;61: 1155–1159. GMO Grains + T. turgidum AABB Aegilops tauschii DD T. aestivum AABBDD 28 chromosomes 14 chromosomes 42 chromosomes 100,000 genes 50,000 genes 150,000 genes The Epidemics Of Gluten Related Disorders - Quality of gluten: GE grains - Quantity of gluten - Gluten cannot be digested 6 11/5/2018 Kasarda D. J Agric Food Chem. 2013;61: 1155–1159 The Epidemics Of Gluten Related Disorders - Quality of gluten: GE grains - Quantity of gluten - Gluten cannot be digested What is so Special About Gluten? Gliadin Glutenin Gluten (gliadin+glutenin) 7 11/5/2018 Structural Characteristics of Alpha-Gliadin Shan L et al, Science. 2002; 297:2275-9. Lammer K et al, Immunology. 2011;132:432-40 Lammer K et al, Gastroenterology Maiuri et al. Scand J 2008;135:194-204. Gastroenterol. 1996; 31:247-53. Celiac Disease The Banana Babies WK Dicke, 1905 - 1962 1st case of CD at UMB: 1938 8 11/5/2018 Celiac Disease as a Unique Model of Autoimmunity • The only autoimmune disease in which specific MHC class II HLA (DQ2 and/or DQ8) are present in >95% of patients; • The auto-antigen (tissue Transglutaminase) is known; • The environmental trigger (gluten) is known; • Elimination of the environmental trigger leads to a complete resolution of the autoimmune process that can be re-ignited following re-exposure to gluten Gastrointestinal Manifestations (“Classic”) Most common age of presentation: 6-24 months • Chronic or recurrent diarrhea • Abdominal distension • Anorexia • Failure to thrive or weight loss • Abdominal pain • Vomiting • Constipation • Irritability Rarely: Celiac crisis Non Gastrointestinal Manifestations Most common age of presentation: older child to adult • Dermatitis Herpetiformis • Iron-deficient anemia • Dental enamel hypoplasia resistant to oral Fe of permanent teeth • Hepatitis • Osteopenia/Osteoporosis • Arthritis • Epilepsy with occipital • Short Stature calcifications • Delayed Puberty Listed in descending order of strength of evidence 9 11/5/2018 The Clinical Manifestations of Celiac Disease are More Heterogeneous Than Previously Appreciated A. Fasano, N Engl J Med 2003;348:2568-70. The Epidemics of Celiac Disease 0.93% 0.45% 0.21% The Epidemics Of Celiac Disease: Which Additional Factors are Driving this Epidemics? - Quality of gluten; - Quantity of gluten; - Breast Feeding; - Timing of gluten introduction - Maturity of gut functions influencing Ag trafficking and handling: -GALT - PRRs - Mucous production - Barrier function - Changes in microbiome composition. 10 11/5/2018 Published on October 2, 2014 Take Home Messages • Window of tolerance concept not supported anymore; • Breast feeding in general or introduction of gluten while breast feeding showed no protective effect on CD onset in at-risk infants; • Early introduction (16 weeks) of gluten traces to potentially induce tolerance did not protect against CD in at-risk infants; • Delaying the introduction of gluten in at-risk infants does not prevent CD but merely postpones its onset by approximately 8 months (significant difference at 2 years FU that disappeared by 5 years FU); • GI infections during the first year of life seems influential in increased the risk of CD onset; • High-risk HLA profiles seems to be the most influential factor predictor of increased risk of CD onset; • The high prevalence of CD among the study cohort suggests that the CD epidemics continues. The Epidemics Of Celiac Disease: Which Additional Factors are Driving this Epidemics? - Quality of gluten; - Quantity of gluten; - Breast Feeding; - Timing of gluten introduction - Maturity of gut functions influencing Ag trafficking and handling: -GALT - PRRs - Mucous production - Barrier function - Changes in microbiome composition. 11 11/5/2018 Key Open Questions Concerning Celiac Disease: • Best diagnostic strategies? • Endoscopy yes/no for diagnosis? • How to properly follow up CD patients? • Should CD patients be actively screened for other autoimmune diseases? • How to manage CD patients with discrepancies between serology and histology? • Are POC tests useful/appropriate for diagnosis and/or management of CD? • Is the GFD highly effective in controlling CD? • How to properly check for gluten cross-contamination? • Are there any alternative/complementary treatments to the GFD at the horizon? Not Only Celiac Disease 12 11/5/2018 Gluten Free Market For the American general population adopting a gluten-free diet is becoming an increasingly popular solution. The market for gluten-free food and beverage products grew at a compound annual growth rate of 28 percent from 2004 to 2011, to finish with almost $6.7 billion in retail sales last year. By the end of 2016 the market is expected to reach about $14.6 billion in sales. How Many People in the US Are Embracing a GFD?: Percentage of U.S. Adults Trying to Cut Down or Avoid Gluten in Their Diets Reaches New High in 2016, Reports NPD The Fad Factor of the GFD 13 11/5/2018 Why People in the US Embrace a GFD?: Approx 7M Approx 400,000 Approx 9M Approx 24M Approx 50M Based on internet interview users age 18y+ who eats GF food The Gluten Free Diet: Not Only Celiac Disease 14 11/5/2018 Gluten Sensitivity (NCGS): Facts Definition Cases of reaction to ingestion of gluten-containing grains in which both allergic and autoimmune mechanisms have been ruled out (diagnosis by exclusion criteria) • Triggered by the ingestion of gluten-containing grains; • Negative immuno-allergy tests to wheat; • Negative CD serology (EMA and/or tTG) and in which IgA deficiency has been ruled out; • Negative duodenal histopathology; • Possible presence of biomarkers
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