A PUBLICATION OF THE UNIVERSITY OF CHICAGO CELIAC DISEASE CENTER CURECELIACDISEASE.ORG AUG | 2018

FOOD INTOLERANCE: AN OVERVIEW By Catherine Degeeter, MD* and Stefano Guandalini, MD**

Food allergies are on the rise, for reasons that are not yet fully understood. However, there is also a tendency to over-estimate them, resulting in parents eliminating foods unnecessarily from their children’s diet. In children, adverse reactions CATHERINE DEGEETER, MD STEFANO GUANDALINI, MD to foods can occur by different mechanisms: Immune-mediated (IgE or not IgE-mediated); autoimmune (celiac disease) or non-immune conditions causing adverse food reactions include congenital or mediated. Diagnosis of food allergy must follow well defined criteria, acquired disorders of digestive-absorptive processes such as lactose avoiding the many “alternative” tests currently available to the intolerance, toxic or pharmacologic reactions, and autoimmune public. Non-celiac gluten sensitivity (better called Non-Celiac Wheat reactions such as celiac disease. Thus, the non-committal term Intolerance) has no biomarkers available and groups a number of “food intolerance” should be used to include all forms of adverse various possible reactions to wheat ingestion. It is a misnomer and reactions due to ingested foods until an adverse reaction is proven should be abandoned in favor of Non Celiac Wheat Intolerance, to be due to an immune mediated process. itself an entity still lacking biomarkers and still not convincingly described in children. AUTOIMMUNE FOOD INTOLERANCE: CELIAC DISEASE INTRODUCTION Celiac disease is the most common genetically induced food Adverse reactions to foods are increasing and are often attributed to intolerance and is an autoimmune disorder affecting 1% of the allergy. Up to a third of parents report one or more food reactions in population. It occurs in individuals of all ages who express the their children that they may interpret as allergies1. However, not all of HLA-Class II haplotypes DQ2 and/or DQ8. Ingestion of gluten these are true intolerances. Food-related disorders can lead to a spec- and related proteins found in wheat, barley, and rye trigger celiac trum of clinical manifestations and severity, only some of which are disease in genetically susceptible individuals. It is characterized related to allergy. In fact, a true food allergy is defined as an “adverse by inflammation that leads to flattening of the small intestinal immune response that occurs reproducibly on exposure to a given mucosa. Gastrointestinal symptoms are prominent, especially food and is distinct from other adverse responses to food”2. Other in younger children, and include abdominal pain, distention, continued on page 2 >

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Dietitian’s Welcome Dr. Rao Meet our partners Calendar of Spring Flours Corner Upcoming Events < continued from page 1 The main treatment for IgE-mediated food allergies remains avoidance of the allergen in all settings, diarrhea, constipation, and rarely malnutri- including home, school, restaurants, and travel. tion and failure to thrive. Extra-intestinal Families should have a written allergy and anaphylaxis manifestations include short stature, iron- deficiency anemia, female infertility, and the emergency plan. typical skin finding of dermatitis herpetifor- mis. Diagnosis involves serologic screening with autoantibodies that are very sensitive have resolution by age 108. Allergies to pea- skin prick tests (SPT) and sIgE testing to and specific: anti-tissue transglutaminase an- nuts and tree nuts are less likely to resolve8. assist in identifying IgE mediated food reac- tibodies (tTG), anti-endomysium antibodies Allergy to seeds, fish and shellfish are also tions. However, positive results alone are not (EMA) and deamidated gliadin peptides considered persistent. diagnostic, so these tests should be used in (DGP)3. The diagnosis is then typically the context of the clinical history and pos- confirmed by duodenal biopsies, which will Why do some children develop food allergies sible food challenge13,14. Physicians should show typical histologic changes in the mu- and others escape them entirely? Risk factors be discouraged from ordering “panels” of cosa. Celiac disease is treated by prompt and for food allergy include a family history of food tests without the appropriate rationale. strict adherence to a life-long gluten free atopy and atopic dermatitis, male gender, The gold standard for allergy diagnosis is diet regardless of presenting symptoms. race/ethnicity (increased in Asian and black a double-blind placebo controlled food children compared to white children), and challenge. However due to expense and FOOD ALLERGY PREVALENCE genetics9. Theories regarding environmental lengthy time requirements, it is rarely used The true prevalence of food allergies is diffi- risk factors for food allergy abound, such as in clinical practice20. Both the NAS report cult to define. The definition of food allergy the hygiene hypothesis, allergen avoidance and NIAID guidelines advice against the is not consistent across prevalence studies. hypothesis, dual allergen exposure hypoth- use of many non-validated tests, such as Prevalence is also influenced by whether the esis, and more9. Other speculations for food allergy patch testing (atopy patch test), diagnosis was self-reported or identified by allergy risk factors that lack firm data include measurement of total IgE, and the basophil testing. These factors, as well as the fact that obesity, processed foods, food additives, and activation test, that have however gained more than 170 foods have been identified genetically modified foods10. some popularity. as causing IgE mediated reactions, limit the reliability of prevalence estimates. How- WHAT DOES A FOOD ALLERGY TREATMENT ever a review published in JAMA in 2010 LOOK LIKE? The main treatment for IgE-mediated food estimated that food allergy affects >1% to IgE mediated reactions to food typically allergies remains avoidance of the allergen in 2% and <10% of the US population4, and a occur within minutes to hours of ingestion. all settings, including home, school, res- study published in Pediatrics determined 8% Different organ symptoms can be involved, taurants, and travel. Families should have a of children have food allergy as identified by including the gastrointestinal tract, skin, written allergy and anaphylaxis emergency parental report5. It is known that self-report- lungs, and heart. In children, the most com- plan16. Intramuscular epinephrine should be ed allergies likely overestimate prevalence6. mon presentations are gastrointestinal, such administered as a first line for emergent treat- as abdominal pain, nausea, vomiting, and ment for food allergy anaphylaxis10,17. Anti- In addition, there are many different types diarrhea (50% to 80%), skin involvement histamines and steroids may also be used in of food allergies. We will address only IgE such as erythema, itching, and urticaria the case of inadvertent ingestion of allergens. mediated food allergy and possibly immune- (20% to 40%) and respiratory symptoms Children with food allergy should be moni- mediated gluten sensitivity here, try to cover of cough, wheezing, and rhinorrhea (4% to tored for nutritional intake and psychosocial others in future IMPACT newsletters. 25%)11. aspects of food allergy management, such as risk of bullying12. Immunotherapy-- giving IGE MEDIATED FOOD ALLERGY Food allergy should be suspected when gradually increasing doses of specific aller- A common myth in the food allergy symptoms occur within minutes to hours gens to induce desensitization and ultimately universe is that a positive IgE test indicates of ingestion of a specific food, especially if tolerance18 --is not currently recommended a food allergy. On the contrary, it shows it occurs on more than one occasion2. Food by any of the major allergy guidelines but sensitivity to that allergen, but not an al- allergy is not a typical trigger of chronic continues to be aggressively explored. lergy. The most common food allergens in asthma or chronic rhinitis so these condi- the United States include cow’s milk, egg, tions should not prompt allergy testing12. PREVENTION OF FOOD peanut, tree nuts, wheat, shellfish, and soy. ALLERGY Cow’s milk proteins followed by soybean DIAGNOSIS OF FOOD ALLERGY Recommendations for the prevention of proteins are the most common cause of food The diagnosis of food allergies is challeng- food allergy have changed in the past few allergy during infancy, while egg protein ing, as there is not a uniform set of criteria decades. Previously allergen avoidance dur- allergy is most common in school-aged to follow4. In addition to the clinical history, ing pregnancy, breastfeeding, and infancy children7. Most food allergies have a high laboratory studies and an oral food chal- was encouraged; however these myths have rate of resolution. About half of all children lenge are often necessary to confirm a diag- been dispelled and numerous studies sug- with a milk, egg, wheat or soy allergy will nosis. The NIAID guidelines recommend gest that early oral exposure may actually

continued on page 3 > 2 | FROM CARE TO CURE continued from page 2 > Condition Clinical Food(s) Diagnostic Suspected involved approach build tolerance. There is also no significant Immediate Usually infancy to Cow’s History+SPT evidence for a protective effect of breast- GI hyper- childhood: reactions milk, soy, and/or sIGE feeding for at risk infants, although many sensitivity to offending food eggs, other public health organizations promote within minutes: peanuts, nursing of all infants through the first 6 vomiting, diarrhea, wheat, 2,10,19 months of life . nausea, pain; also shellfish rhinoconjunctivitis, TIMING AND INTRODUCTION skin rash, angioedema OF COMPLEMENTARY FOODS There is evidence that very early (during the Food protein- Early infancy: streaks Cow’s Clinical diagnosis first 2-3 months of life) introduction of po- induced of blood and mucus milk, eggs, supported by tential allergens put infants at an increased proctocolitis in stools in breast- soy, corn food elimination risk for allergies. However there is no con- fed, typically healthy (in moth- in mother’s diet vincing data that delaying introduction of babies er’s diet) solid foods beyond 4-6 months of age has any protective effect on the development of food allergy. In the Learning Early About FPIES Early infancy: Rice, soy, Clinical criteria Peanut (LEAP) trial infants at high risk of vomiting, diarrhea, cow’s milk, +/- food peanut allergy (severe eczema or egg allergy) colitis vegetables, challenge were randomized to receive or avoid peanut fruits, oats, to the age of 5 years. The children sensi- meat, fish tized to peanut had a peanut allergy rate of 10.6% compared to those in the avoid- Food protein- Infants and toddlers: Cow’s milk, Clinical diagnosis ance group who had peanut allergy rate of induced malabsorption occasionally supported 35.3% (P = .004; relative risk reduction enteropathy syndrome similar soy or egg by duodenal 70%)20. The AAP, NAS and NIAID guide- to early-onset biopsies with lines all recommend early introduction of celiac disease, patchy villous peanuts in infants at high risk. Delaying the hypoalbuminemia atrophy introduction of egg, cow milk, and wheat 10 seems to have no benefits either . Eosinophilic All ages: Cow’s milk, Endoscopy with esophagitis asymptomatic, soy, eggs, biopsies showing POSSIBLY IMMUNE-MEDIATED: reflux-like symptoms, peanuts, typical changes. GLUTEN SENSITIVITY dysphagia wheat, SPT, sIgE Gluten consumption has been linked shellfish sometimes useful to a wide range of disorders, including celiac disease, wheat allergy, dermatitis Eosinophilic Highly variable Cow’s milk, Endoscopy with herpetiformis, gluten ataxia, peripheral gastro- symptoms depending soy, eggs, biopsies neuropathy, and possibly this relatively new enteropathy on localization peanuts, entity called “non celiac gluten sensitivity and extension of wheat, (NCGS).” eosinophilic infiltrates shellfish

These patients by definition do not meet Gluten Mostly adults with Gluten Clinical only: the criteria for celiac disease or wheat al- sensitivity IBS-like symptoms no diagnostic lergy, but report experiencing a number of marker available intestinal and/or extra-intestinal symptoms after consuming gluten-containing foods3. Celiac All ages. Strictly Gluten Specific They present neither the autoantibodies disease limited to HLA-DQ2 serology+ nor the enteropathy characteristic of celiac and/or DQ8 subjects. diagnostic disease. In NCGS, symptoms typically GI and extra-GI features of occur soon after ingestion of gluten-con- symptoms duodenal taining foods and disappear quickly after biopsies elimination of wheat-related foods. Upon Lactose Increases with age: Lactose Clinical, breath reintroduction of wheat, rapid relapse typi- intolerance abdominal pain, hydrogen cally occurs. The clinical manifestations are bloating, flatulence, testing, mostly, but not exclusively, gastrointestinal, diarrhea duodenal and are similar to those of irritable bowel biopsy continued on page 4 > 3 | FROM CARE TO CURE continued from page 3 > ment of Food Allergy in the United States: 2001;107(5):891-896. syndrome (IBS). In 2015, one of us pro- Summary of the NIAID-Sponsored Expert posed that “NCGS is a misnomer and prob- Panel Report. J Allergy Clin Immunol. 15. Sampson HA, Gerth van Wijk R, ably an umbrella term including various 2010;126(6):1105-1118. Bindslev-Jensen C, et al. Standardizing 21 double-blind, placebo-controlled oral food clinical entities” . With time, it has become 3. Hill ID, Fasano A, Guandalini S, et al. challenges: American Academy of Allergy, even more clear that this entity encompasses NASPGHAN Clinical Report on the Di- Asthma & Immunology-European Acad- various, distinct populations: while a small agnosis and Treatment of Gluten-related emy of Allergy and Clinical Immunology minority may indeed react to gluten itself, Disorders. J Pediatr Gastroenterol Nutr. PRACTALL consensus report. J Allergy Clin the majority appear to react to FODMAPs, 2016;63(1):156-165. Immunol. 2012;130(6):1260-1274. and among them especially fructans, as 4. Chafen JJ, Newberry SJ, Riedl MA, et 16. Wang J, Sicherer SH, Section On A, Im- elegantly demonstrated by Skodje et al. in al. Diagnosing and managing common munology. Guidance on Completing a Writ- 201722 (See figure 1). But these patients food allergies: a systematic review. JAMA. ten Allergy and Anaphylaxis Emergency 2010;303(18):1848-1856. Plan. Pediatrics. 2017;139(3). may also react to a series of proteins found in wheat grouped under the name of ATI 5. Gupta RS, Springston EE, Warrier MR, et 17. Sicherer SH, Simons FER, Section On (Amylase-Trypsin Inhibitors)23; or to wheat al. The prevalence, severity, and distribu- A, Immunology. Epinephrine for First-aid 24 tion of childhood food allergy in the United Management of Anaphylaxis. Pediatrics. with non-IgE mediated mechanisms ; or States. Pediatrics. 2011;128(1):e9-17. 2017;139(3). indeed may simply respond to the placebo/ nocebo effect25. It is also important to notice 6. Rona RJ, Keil T, Summers C, et al. The 18. Gernez Y, Nowak-Wegrzyn A. Im- prevalence of food allergy: a meta-analysis. munotherapy for Food Allergy: Are We that in spite of numerous reports in the J Allergy Clin Immunol. 2007;120(3):638- There Yet? J Allergy Clin Immunol Pract. adult literature, this entity has not been ad- 646. 2017;5(2):250-272. equately demonstrated in children. It cannot 7. Sicherer SH, Munoz-Furlong A, God- 19. Greer FR, Sicherer SH, Burks AW, be overemphasized how important it is to bold JH, Sampson HA. US prevalence of American Academy of Pediatrics Commit- first rule out the existence of celiac disease self-reported peanut, tree nut, and sesame tee on N, American Academy of Pediatrics or wheat allergy before considering NCWI. allergy: 11-year follow-up. J Allergy Clin Im- Section on A, Immunology. Effects of early munol. 2010;125(6):1322-1326. nutritional interventions on the develop- CONCLUSIONS ment of atopic disease in infants and chil- 8. Savage J, Sicherer S, Wood R. The Na- dren: the role of maternal dietary restric- Not all adverse reactions are due to food al- tural History of Food Allergy. J Allergy Clin tion, breastfeeding, timing of introduction lergy, and an excellent history is the essential Immunol Pract. 2016;4(2):196-203; quiz of complementary foods, and hydrolyzed first step in making the proper diagnosis. 204. formulas. Pediatrics. 2008;121(1):183-191. The clinical history will guide appropriate 9. Sicherer SH, Sampson HA. Food allergy: 20. Du Toit G, Roberts G, Sayre PH, et al. testing selection. A positive sIgE or SPT A review and update on epidemiology, Randomized trial of peanut consumption in alone is not sufficient to make a diagno- pathogenesis, diagnosis, prevention, and infants at risk for peanut allergy. N Engl J management. J Allergy Clin Immunol. Med. 2015;372(9):803-813. sis – testing indicates sensitization but 2018;141(1):41-58. not necessarily clinical allergy. Finally, it is 21. Guandalini S, Polanco I. Nonceliac imperative to keep in mind that patient and 10. National Academies of Sciences Engi- gluten sensitivity or wheat intolerance syn- neering and Medicine (U.S.). Committee drome? J Pediatr. 2015;166(4):805-811. parental reported food allergies are often on Food Allergies: Global Burden Causes not substantiated by allergy testing and may Treatment Prevention and Public Policy, 22. Skodje GI, Sarna VK, Minelle IH, et prompt investigation of other non-allergy Stallings VA, Oria M, National Academies of al. Fructan, Rather Than Gluten, Induces causes of food intolerance. Table 3 Diagnos- Sciences Engineering and Medicine (U.S.). Symptoms in Patients With Self-reported tic approach for food intolerances Finding a path to safety in food allergy : Non-celiac Gluten Sensitivity. Gastroenter- assessment of the global burden, causes, ology. 2017. prevention, management, and public policy. Washington, DC: The National 23. Zevallos VF, Raker V, Tenzer S, et al. REFERENCES Academies Press; 2017. Nutritional Wheat Amylase-Trypsin Inhibi- * Division of Gastroenterology, Hepatology, tors Promote Intestinal Inflammation via Pancreatology, and Nutrition, Stead Fam- 11. Sicherer SH, Sampson HA. Food allergy. Activation of Myeloid Cells. Gastroenterol- ily Department of Pediatrics University of J Allergy Clin Immunol. 2010;125(2 Suppl ogy. 2017;152(5):1100-1113 e1112. Iowa Health Care, Iowa City, IW 2):S116-125. 24. Carroccio A, Mansueto P, D’Alcamo A, **Founder, University of Chicago Celiac 12. Sicherer SH, Allen K, Lack G, Taylor SL, Iacono G. Non-celiac wheat sensitivity as Disease Center and Professor Emeritus and Donovan SM, Oria M. Critical Issues in Food an allergic condition: personal experience Chief, Section of Pediatric Gastroenterol- Allergy: A National Academies Consensus and narrative review. Am J Gastroenterol. ogy, Hepatology and Nutrition Report. Pediatrics. 2017;140(2). 2013;108(12):1845-1852; quiz 1853. University of Chicago 13. Sampson HA, Ho DG. Relationship 25. Molina-Infante J, Carroccio A. Suspect- 1.Pyrhonen K, Nayha S, Kaila M, Hiltunen between food-specific IgE concentrations ed Nonceliac Gluten Sensitivity Confirmed L, Laara E. Occurrence of parent-reported and the risk of positive food challenges in in Few Patients After Gluten Challenge in food hypersensitivities and food allergies children and adolescents. J Allergy Clin Im- Double-Blind, Placebo-Controlled Trials. among children aged 1-4 yr. Pediatr Allergy munol. 1997;100(4):444-451. Clin Gastroenterol Hepatol. 2017;15(3):339- Immunol. 2009;20(4):328-338. 348. 14. Sampson HA. Utility of food-specific 2. Boyce JA, Assa’ad A, Burks AW, et al. IgE concentrations in predicting symptom- Guidelines for the Diagnosis and Manage- atic food allergy. J Allergy Clin Immunol.

4 | FROM CARE TO CURE DIETITIAN’S CORNER By Lori Welstead, MS, RD, LDN ARSENIC AND THE GLUTEN-FREE DIET

In the past few years, much has rice was grown. Rice grown in the south- been written about the risk of central US contains higher total arsenic arsenic in rice. Because those on a concentrations compared to rice grown in gluten-free diet tend to eat more rice and California. It is believed that the higher rice-based products, this has been a concern concentration of arsenic is due to arsenic- in the gluten-free community. My hope is based pesticides that were often used to to provide some perspective and realistic rec- treat the cotton crops in the southern ommendations for a healthy and balanced United States.4 Secondly, cooking rice as if gluten-free diet. it were pasta can reduce the amount of ar- REFERENCES: senic in rice. This requires draining off the 1 First, what is arsenic, exactly? According to excess water, which diminishes the amount Signes-Pastor, A., M. Carey, and A. 5 Meharg. Inorganic arsenic in rice-based the National Institutes of Health, arsenic is of inorganic arsenic. Brown rice contains products for infants and young children. a naturally occurring element.* It is fairly more arsenic as it concentrates near the Food Chemistry. 2016; 191: 128-134. surface of the grain, which is polished to common in drinking water that is sourced 2 6 US Food and Drug Administration. from wells, and in food, it appears most create white rice. However, brown rice Arsenic in Rice and Rice Products. Updated frequently in rice and some fish. Arsenic can has greater nutritional content than white 2014. Available at: affect many of the body’s systems in a nega- rice. Look for brown basmati rice grown in www.fda.gov/Food/ tive way, and can be particularly disruptive India, California and Pakistan—rice from FoodborneIllnessContaminants/ these areas has less arsenic, according to a to children in early stages of development.* Metals/ucm319870.htm Children have dietary arsenic exposure from 2015 Consumer Reports article.7 2 to 3 times greater than that of adults and 3 Raehsler SLR, et al. Accumulation of 1 Finally, take stock of your rice intake and Heavy Metals in People on a Gluten- may be the most vulnerable. In April 2016, Free Diet. Clinical Gastroenterology and the FDA proposed an action level, or limit, change up the types of grains you consume. Hepatology 2018; 16: 244-51. of 100 parts per billion (ppb) for inorganic Incorporate quinoa, millet, amaranth and 4 2 teff for whole grains. Consider your intake RD Watkins et al. Arsenic Levels in Celiac arsenic in infant rice cereal. Patients. Practical Gastroenterology. of refined rice products (cereal, crackers, January 2018:12-18. A recent study found that those on a strict bars), and look for those with a variety 5 of gluten-free grains. If you drink rice US Food and Drug Administration. gluten-free diet had significantly higher arse- Arsenic in Rice and Rice Products. Updated nic in urine than those that were not avoiding milk due to a dairy intolerance, try to use 2014. Available at: gluten.3 It is important to note that arsenic in other types of “milks” such as soy, almond, water is restricted to only 10 parts per billion cashew, coconut and hemp instead. Look www.fda.gov/Food/ FoodborneIllnessContaminants/ (ppb). There are two types of arsenic: organic for other sources of starch and fiber such as Metals/ucm319870.htm and inorganic. Organic arsenic from animal potatoes, tapioca, squash and corn that are and plants is rapidly eliminated, while excess typically low in arsenic. Aim to eat more 6 Signes-Pastor, A., M. Carey, and A. intake of inorganic arsenic, which is the type colors of the rainbow and fewer processed Meharg, Ibid. in rice, can have toxic effects. gluten-free products for a more balanced, 7 Consumer Reports: How much arsenic is lower-arsenic diet. in your rice? www.consumerreports. How can you reduce the amount of arsenic org/cro/magazine/2015/01/how- you ingest through rice and rice-based *www.niehs.nih.gov/health/topics/ much-arsenic-is-in-your-rice/index. products? First, try to find out where the agents/arsenic/index.cfm htm

5 | FROM CARE TO CURE GOING

FORWARD Stefano Guandalini, MD FOUNDER & MEDICAL DIRECTOR The University of Chicago is building Section Chief The University of Chicago Comer Children’s Hospital, Pediatric Gastroenterology, a Celiac Disease Center for the 21st Hepatology and Nutrition Century and beyond. This next Bana Jabri, MD, PhD critical phase will establish the Center Director of Research as an international hub for clinical Hilary Jericho, MD, MSCI trials. These trials will allow the Director of Pediatric Clinical Research Center to follow the response to new Welcome, Dr. Rao! The University of Chicago Celiac Sonia Kupfer, MD treatments and to understand why Director of Clinical Genetic Research some patients respond, and others Disease Center welcomes Dr. Vijaya Rao to our roster of adult Carol Semrad, MD do not. These robust studies, which celiac disease experts. Dr. Rao Director of Adult Clinical Research will provide an understanding of the is an adult gastroenterologist Lori Rowell Welstead, MS, RD, LDN disease at the mechanistic level, are with a special interest in celiac Nutrition Advisor critical in applying the promise of disease and small bowel precision medicine to celiac disease. disorders. She is originally from STAFF MEMBERS Milwaukee, WI. She completed Carol M. Shilson, Executive Director The University of Chicago Celiac her undergraduate studies at Ronit Rose, Program Director Disease Center continues to break Northwestern University and completed medical school and ground in the search for a cure. And GENERAL OFFICE INFORMATION we are closer than ever. Our world her Internal Medicine Residency 5841 S. Maryland Avenue, MC 4069 renowned experts are studying this at Loyola University Chicago. She Chicago IL 60637 complex auto-immune disorder subsequently completed two 773-702-7593 fellowships, in Gastroenterology from every angle to find new ways and in Clinical Medical Ethics, www.CureCeliacDisease.org Facebook: cureceliac to treat and cure it. To learn more at the University of Chicago about this important effort to donate Twitter: @cureceliac Medicine. Dr. Rao’s research Instagram: uchicagoceliaccenter to support it, please go to www. focuses on the ethical implications cureceliacdisease.org. of invasive procedures and clinical research trials. To schedule an appointment with Dr. Rao, please call A Cure for (773) 702-6140. Celiac Disease PARTNERS: is possible ...

The University of Chicago Celiac Disease Center is required to raise We are its own funding, for research and programming, every year. Our partners making it happen. are an important part of this effort. We are pleased to partner with the companies listed here, and we thank them for their support.

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6 | FROM CARE TO CURE CALENDAR of Upcoming Events:

SEPTEMBER 29, 2018: DR. Annual Meeting Nutrition RECENT AND UPCOMING HILARY JERICHO of The Celiac Symposium in Hollywood, FL. Her PUBLICATIONS Center will give the keynote talk is on “Optimal Diagnosis and In addition to all of the lectures lecture at the annual Iowa Celiac Management of Celiac Disease.” and meetings, two publications Conference, titled “Advances in November 11, 2018: Dr. Guandalini are about to be published on Celiac Disease,” in Iowa City. lectures on “Celiac disease: research conducted at The New Challenges” at the Grand University of Chicago Celiac OCTOBER 4, 2018: DR. Rounds Lecture at the University Disease Center: GUANDALINI will present: of Wisconsin Medical College, “25 years of the Italian Society Milwaukee. Amirikian K, Sansotta N, of Pediatric Gastroenterology, Guandalini S, Jericho H. 2018. Hepatology and Nutrition: Effect of the gluten free diet on A View from a Past President” DECEMBER 6, 2018: DR. body mass indexes in pediatric in Salerno, Italy. GUANDALINI presents “Feeding celiac patients. JPGN. (Submitted the celiac child: yesterday, but not yet published). OCTOBER 27, 2018: DR. JERICHO today and tomorrow,” at the is an invited speaker at the North Postgraduate Course “The Child Jericho H, Guandalini S. 2018. American Society for Pediatric between Feeding and Culture.” Extra-intestinal Manifestation Gastroenterology, Hepatology University of Palermo Department of Celiac Disease in Children. and Nutrition ( NASPGHAN) of Pediatrics, Palermo, Italy, Nutrients. June 2018, 10(6), 755.

SPRING FLOURS SPRUNG AGAIN! Once again we gathered together at Spring Flours to raise funds for the very important research going on in Dr. Jabri’s lab. This year was even more noteable as we honored Dr. Guandalini’s many years of service and long list of accomplishments at the event. The keynote speech, given by his mentee, Dr. Valentina Discepolo, was especially mov- ing. Aside from the scrumptious gluten-free tastings of many of Chicago’s finest chefs and bakers, Spring Flours 2018 was topped off with the introduction of the Carlino family of Pennsylvania who recently made the Center’s largest-ever gift to establish and endow The Alissa and Gianna Carlino Fellowship in Celiac Disease Research to fund a post-doctoral researcher who will be dedicated to better understanding celiac disease, developing new treatments, finding a cure and training future investigators. For photos of this remarkable evening, please click here https:// uchicagoceliaccenter.shutterfly. com/pictures 7 | FROM CARE TO CURE DR. GUANDALINI’S NEXT CHAPTER

GUANDALINI FESSCRIF RECEPION DINNER PROGRA SAURDA A , P A GUAA CICAGO EOLOGICAL SEINAR A GLUTEN-FREE RECEPTION & DINNER HOSTED BY THE UNIVERSITY OF CHICAGO CELIAC DISEASE CENTER A 2018 ODA WE GAER O CELERAE E CAREER OF A REARALE AN, A DOCOR, RESEARCER, USAND, FAER, GRANDFAER AND FRIEND. Dr. Guandalini’s accomplishments and breakthroughs are far too numerous to mention OVER THE PAST YEAR, DR. GUANDALINI,here, but suffice it to WHILEsay, he has altered theSTILL course of history: his early discoveries in gastroenterology, specifically celiac disease and diarrheal diseases, and his treatment and advocacy of those with celiac disease have truly changed the world and touched so ACTIVELY INVOLVED IN THE CELIACmany lives.DISEASE We thank Dr. Guandalini CENTER, for his efforts and tireless HAS work over the years, TRANSITIONED TO PROFESSOR EMERITUS ALLOWINGand celebrate his legacy today. HIM RECEPTION—LOBBY LEVEL PASSED ORS D’OERES TO REDUCE HIS HEAVY PATIENT ROSTERSirloin Carpaccio on ASParmesan WELL Frico / Smoked AS Chicken HIS and Cherry Quesadilla Tequila Lime Shrimp / Cabrales Pepper E IS A ADMINISTRATIVE AND ACADEMIC RESPONSIBILITIES.Music at the reception provided by Celebration However, Strings. DINNER—SKYLINE CHAPEL AN WI lest anyone think he is in full retirement mode, think again. In additionN to the travel and Kale Salad lectures listed above, he recently completed the following: Oven Roasted French Chicken Breast SUC RIC garlic roasted tri color fingerlings, asparagus custard, tomato shallot beurre rouge OR CONRIUIONS Carnaroli Risotto In May, he attended the 51st Meeting of the Europeangolden beets, Society preserved lemon, for toasted Pediatric hazelnuts, grana padano cheese IN SO AN Gluten Free Vanilla & Chocolate with Vanilla Buttercream Gastroenterology, Hepatology and Nutrition (ESPGHAN)Dinner Rolls &in Cake Geneva, by Sweet Ali’s Switzerland,Gluten-Free Bakery SPERES, for a Symposium on Celiac Disease; in June, he delivered four lecturesWINES at the Pan 2015 Badia a Coltibuono Chianti Classico / 2016 Jermann Sauvignon Blanc WI American Symposium on Intestinal Diseases in Buenos Aires, ArgentinaPROGRA (all delivered Emcee, Ankur Chugh, MD UANI EING telematically): Camagne oast John M. Cunningham MD George M. Eisenberg Professor and Chairman, Department of Pediatrics, The University of Chicago E FOCAL Diagnosis of celiac disease in children: a paradigmCello Perormancein evolution Andrea Nocerino POIN IN ALL. riute ideo How to manage celiac children after diagnosis Remars Relections rinalini C Rao PhDAGAF Lilly Guandalini Nataf, Chiara Nataf (granddaughter), Hugo Nataf (grandson), Maria Carulli niversity o Illinois at Chicago Proessor Department o Physiology iophysics Chair niversity Senates Conerence Gluten intolerance: all the evils of wheat. Comilation o commentar rom around te gloe SPECIAL ANS O ANDREA NOCERINO, FOR IS USICAL PRESENAION. Probiotics in gastrointestinal pediatric diseases: where are we now? And finally, at the end of June, he traveled to Albuquerque, NM, to lecture on “All Wheat: Celiac Disease and Surroundings,” at Grand Rounds at the University of New It is clear that Dr. Guandalini has no Mexico Children’s Hospital. intention of pulling back on his efforts to raise awareness of celiac disease, to educate medical On May 5, 2018, a number of Dr. Guandalini’s colleagues from Italy and the U.S. professionals on how to treat it and to support came to Chicago to celebrate his medical and academic achievements on the eve of his ongoing research efforts. Thank you, Dr. retirement. This honor, known in academic circles as a “festschrift,” is reserved for those Guandalini for your unbelievable efforts and who have reached the highest levels of academia. The lectures ranged from scientific accomplishments to further the mission of The presentations to reminiscences of Dr. Guandalini’s career and even his wedding. The Celiac Disease Center over the last 18 years, group gathered for dinner that evening, which featured speeches by those closest to Dr. and we hope you make some time for well Guandalini, as well as a special cello performance by Italian cellist Andrea Nocerino. deserved rest and relaxation.

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