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Pre-Test

! 1. What is Gluten? GLUTEN DISEASES– WHAT’S A. An additive to many ALL THE BUZZ ABOUT? B. A preservative C. A protein found naturally in certain foods Megan Huff PA-C D. A flavoring

! 2. Which is a symptom of gluten intolerance? ! 3. Eating gluten-free is critical if you… A. Poor Circulation A. Want to lose weight B. Sore Throat B. Want to cleanse your digestive tract C. Diarrhea C. Want to have more energy D. Ringing in the ears D. Have celiac disease ! 5. Which grain does not contain gluten? ! 4. There is no test for Celiac Disease A. Rye A. TRUE B. B. FALSE C. Wheat D.

! 6. You can tell which prepared foods have ! 7. You Can’t drink alcohol if you’re on a gluten- gluten just by looking at them. free . A. TRUE A. TRUE B. FALSE B. FALSE ! 8. Which is a good gluten-free breakfast choice? ! 9. Which department should you spend the A. Toast with butter most time in when shopping for gluten-free B. Scrambled Eggs and grits ? C. Bagel and cream cheese A. Frozen prepared foods D. Pancakes B. Snack food C. Produce D. Cereal

! 10. Some parents believe eating gluten-free ! 11.Which snack is off-limits on a gluten –free helps children with: diet? A. Dyslexia A. Pretzels B. Autism Spectrum Disorder B. Tortilla chips C. Hyperactivity C. Rice cake D. Tonsilitis D. Popcorn Objectives

! 12. Which restaurant entrée is a good gluten- ! 1. Understand Gluten Enteropathies and long free choice? term complications. A. Chicken Parmesan ! 2. Know how to diagnosis gluten enteropathies B. New York Strip ! 3. Understand the pro/con of gluten free diets C. Fried Strip ! 4. Understand the pitfalls of gluten free diet and D. Fajitas how to overcome them.

Gluten Enteropathies Celiac Disease

! Celiac Disease ! Celiac disease is an immune reaction to eating ! Non-Celiac Gluten Sensitivity gluten, a protein found in wheat, barley and rye. ! Subsequently eating gluten triggers an immune response in your small intestine. ! Over time, this reaction produces inflammation that damages the small intestine's lining and prevents absorption of some key . Celiac Disease

! Experts estimate that about 1% of Americans have celiac disease. ! A study done by Mayo Clinic and the National Institutes of Health estimates that about 1 in 141 people in the U.S. have celiac disease This may be greater because the disease often goes undiagnosed. ! Celiac disease is most common in Caucasians. ! Some gene mutations appear to increase the risk of developing the disease. Having those gene mutations doesn't mean you'll get celiac disease — SO… other factors must be involved. ! Sometimes celiac disease is triggered — or becomes active for the first time After surgery Pregnancy and/or childbirth Infection Severe emotional stress.

Who is at risk? Symptoms of Celiac disease

! Celiac disease can affect anyone. ! Celiac disease has numerous symptoms. ! Tends to be more common in people who have: According to some experts, there are about 300 possible symptoms of the disease. A family member with celiac disease or dermatitis ! herpetiformis Symptoms vary greatly from one person to the next based on the nutrients that are missing due Type 1 diabetes to malabsorption. Down syndrome or Turner syndrome This can make diagnosing the disease challenging. Autoimmune thyroid disease Often, symptoms of celiac disease are confused with Sjogren's syndrome other disorders: Microscopic colitis (lymphocytic or collagenous ▫ Irritable bowel syndrome colitis) ▫ Lactose intolerance. ! Symptoms of Celiac disease involve GI distress in various forms, but other symptoms are often a direct reflection of the missing being absorbed including: Celiac - Symptoms in Infants ! Anemia Iron, B ! Infants and children with celiac disease tend to have digestive ! Osteopenia, osteoporosis, osteomalacia problems. Calcium, Vit D, Phosporous ! Common symptoms for infants and children include: ! Itchy, blistery skin rash (dermatitis herpetiformis) Growth problems ! Damage to dental enamel Decreased appetite and failure to gain weight Chronic diarrhea, which can be bloody Calcium, Vit D, Phosphorous, others Chronic constipation ! Headaches and fatigue Vomiting Numerous nutrient deficiencies Abdominal bloating and pain ! Nervous system injury, including numbness and tingling in Fatigue the feet and hands, and possible problems with balance Irritability B vitamins and many other ! Children may also show physical signs of ! Joint pain malnourishment. The stomach may expand, ! Reduced functioning of the spleen (hyposplenism) while the thighs become thin and the ! Acid reflux and heartburn buttocks flat.

! There is variation in symptoms based on age.

Celiac – Symptoms in Children Celiac – Symptoms in Teens

! ! For teens with celiac disease, symptoms may not occur until they are Diarrhea triggered by something stressful, such as: ! Leaving home for college Constipation Suffering an injury or illness ! Pregnancy Short stature ! Common symptoms for teenagers include: ! Delayed puberty Delayed puberty Growth problems ! Diarrhea Neurologic symptoms: Abdominal pain and bloating Attention-deficit/hyperactivity disorder (ADHD) Weight loss Fatigue Learning disability Irritability Depression Headaches Dermatitis herpetiformis (itchy skin rash that looks like eczema or poison ivy) Lack of muscle coordination Mouth sores Dermatitis Herpetiformis Image of dermatitis herpetiformis

! Dermatitis herpetiformis is an itchy, blistering skin disease that stems from intestinal gluten intolerance. The rash usually occurs on the elbows, knees, torso, scalp and buttocks. ! Associated with changes to the lining of the small intestine identical to that of celiac disease, but the disease may not produce noticeable digestive symptoms. ! Dermatitis herpetiformis is treated with a gluten-free diet and medication to control the rash.

! Common symptoms for Celiac – Challenges in Teens Celiac – adults include: Symptoms in Iron deficiency ! Challenges facing teens with Celiac Adults Bone or joint pain Feeling “different” Arthritis Eating at special events / functions Depression or anxiety Adults often have fewer Bone loss or osteoporosis School lunches are not specifically available in gluten gastrointestinal free and cross contamination is harder to control. symptoms of celiac Tingling numbness in hands and feet ▫ Even more challenging in lower income that depend on disease. Diarrhea, for lunch programs example, affects only Seizures one-third of adults with Friends and family “don’t get it”. Erratic menstrual periods, the disease. infertility, and miscarriages Dermatitis herpetiformis Mouth sores Factors influencing symptoms

! How long the patient was breastfed ! Age of patient when gluten was introduced to the diet ! How much damage the disease has done to the intestine before it was diagnosed ! How much gluten the patient's diet contained

Symptoms across all ages Causes of Celiac Disease

! Exact cause is not know. ! When the body's immune system overreacts to gluten in food, the immune reaction damages the tiny, hair-like projections (villi) that line the small intestine ! Eventually with enough damage you are unable to absorb nutrients. Long-term complications of CD Establishing the Diagnosis

! Two approaches to the diagnosis of Celiac disease ! Malnutrition Screening vs. Diagnostic testing. This can lead to anemia, weight loss, and in children stunted growth / delayed development. 1. Screening ! Liver diseases ▫ Who should be screened? ! Children older than 3 and adults experiencing symptoms of celiac disease ! Loss of Calcium & Bone Density ! First-degree relatives of people with celiac disease (parent, child, sibling) Children: Osteomalacia or Rickets ! Any individual with a related autoimmune disorder Adults: Osteoporosis ▫ There are several serologic (blood) tests available that screen for celiac disease ! of the intestine (in rare cases) antibodies, but the most commonly used is called a tTG-IgA test. ! The importance of recognizing symptoms early -- and ▫ If test results suggest celiac disease, follow up with scope and biopsy of small beginning a gluten-free diet -- is hard to overstate. intestine to confirm the diagnosis. ! In children and teens, the disease can stunt growth and ▫ IMPORTANT: Patient must NOT be on a gluten-free diet for screening. delay or shorten puberty. ! If patient has been on a gluten-free diet it is recommend a daily ! Hair loss and dental problems may also occur among consumption of gluten equivalent to at least 4 slices of bread for one to young people who continue to eat gluten. three months followed by an endoscopic biopsy with no serology testing.

Establishing the Diagnosis Marsh Stages by Imaging ! 2. Diagnostic Testing: Final diagnosis is made with EGD + Biopsy of the small intestine being positive. This is often classified in Marsh Stages.

! Marsh Stages ! Marsh 0: The mucosa (intestinal lining) is normal, so celiac disease is unlikely. Stage 0 is known as the “pre-infiltrative stage.” ! Marsh I: The cells on the surface of the intestinal lining (the epithelial cells) are being infiltrated by white blood cells known as lymphocytes. This is also seen in tropical sprue, giardiasis, acute infective enteropathy, H. pylori gastritis, Crohn’s disease, during NSAID usage, and in various autoimmune disorders. Therefore, it is not specific for celiac disease. Stage 0 Stage 1-2 ! Marsh II: The changes of Marsh I are present (increased lymphocytes), and the crypts (tube-like depressions in the intestinal lining around the villi) are “hyperplastic” (larger than normal). ! Marsh III: The changes of Marsh II are present (increased lymphocytes and hyperplastic crypts), and the villi are shrinking and flattening (atrophy). Most patients with celiac disease are Marsh III. There are three subsets of Marsh III: Partial villous atrophy, Subtotal villous atrophy and Total villous atrophy. ! Marsh IV: The villi are totally atrophied (completely flattened) and the crypts are now shrunken, too. Stage 3 Stage 4 Non-Celiac Gluten Sensitivity Treatment

! Gluten Sensitivity ! Must follow strict Gluten-free Diet Not all people who react negatively to gluten actually ! People with celiac disease who eat a gluten-free diet have celiac disease. experience fewer symptoms and complications of the disease. The symptoms of gluten sensitivity are similar to ! those of celiac disease. People with celiac disease must eat a strictly gluten- free diet and must remain on the diet for the People who are gluten sensitive experience remainder of their lives. symptoms in response to eating gluten, but will not Even small slip-ups on diet plan can cause damage have intestinal damage and will test negative for internally even if no physical symptoms at the time. celiac disease antibodies. ! In some severe cases, a gluten-free diet alone can't stop the symptoms and complications of celiac disease, and additional treatment is needed.

Gluten Free Diet How to follow gluten free diet

! A gluten-free diet is a diet that excludes the ! ALLOWED FOODS ! ACCEPTABLE GRAINS: protein gluten. ! Beans, seeds and nuts in ! Beans, seeds and nuts in their natural, their natural, ! Gluten is found in grains such as wheat, barley, unprocessed form unprocessed form rye, and a cross between wheat and rye called ! Fresh eggs ! Fresh eggs triticale. ! Fresh meats, fish and ! Fresh meats, fish and poultry (not breaded, poultry (not breaded, batter-coated or batter-coated or marinated) marinated) ! Fruits and vegetables ! Fruits and vegetables ! Most dairy products ! Most dairy products How to follow gluten free diet How to follow gluten free diet

! Avoid all food and drinks containing: ! Avoiding wheat can be challenging because Barley (malt, malt flavoring and malt vinegar are wheat products go by numerous names. usually made from barley) ▫ Consider the many types of wheat flour on supermarket shelves — bromated, enriched, phosphated, plain and Rye self-rising. Here are other wheat products to avoid: Durum flour Farina Graham flour Triticale (a cross between wheat and rye) Kamut Wheat Semolina

! Beer How to follow ! Breads ! Cakes and pies How to follow gluten free diet gluten free diet ! Candies ! Cereals ! ! Communion wafers Watch for cross-contamination ! CAUTION!!! ! Cookies and crackers Cross-contamination occurs when gluten-free foods come into contact ! Croutons with foods that contain gluten Manufacturing process is common cause ! French fries ! Some food labels include a "may contain" statement if cross- ! Gravies In general avoid the contamination is likely. ! Imitation meat or seafood Be aware that this type of statement is voluntary. following foods ! Matzo ! Foods may also be labeled as "gluten-free” and still contain gluten. ! Pastas unless specifically If a product carries a gluten-free label, the Food and Drug Administration marked as GLUTEN ! Processed luncheon meats requires that the product contain less than 20 parts per million of gluten. ! Salad dressings ! FREE. Be aware that products labeled "wheat-free" may still contain gluten. ! Sauces, including soy sauce ! You still need to check the actual ingredient list. If you're not sure ! Seasoned rice mixes whether a food contains gluten, don't buy it or check with the ! Seasoned snack foods, such as potato and manufacturer first to ask what it contains. tortilla chips ! Self-basting poultry ! Soups and soup bases ! Vegetables in sauce How to follow gluten free diet Advantages to GFD

! WATCH FOR CROSS –CONTAMINATION: ! Decreased GI inflammation and irritation ! At home: ! Decreased bloating / gas ! Increased energy Foods are prepared on common surfaces or with utensils that weren't thoroughly cleaned after being used to ! Some reports of decreased inflammation in conditions prepare gluten-containing foods. such as Crohn’s, RA, Lupus, and other chronic inflammatory conditions. Using a common toaster for gluten-free bread and regular bread is a major source of contamination ! TAKE NOTE: ! In the public: Be careful about eating out at A food billed as “gluten-free" isn't necessarily healthier. restaurants. ▫ Can be high in calories, fat, and carbohydrates Ask restaurant staff members if they have choices that are ▫ Some people who go gluten-free actually gain weight. truly gluten-free, including being prepared so as to avoid That said, so long as you continue to eat a balanced diet, cutting cross-contamination. gluten probably won't cause any harm. ▫ May want to consider Multivitamin though.

Pitfalls of Gluten Free Diet Pitfalls of Gluten-Free Diet

! Can be dangerous to those who don’t need Gluten- ! Gluten-free products tend to be low in a wide free Diet range of important nutrients May lack vitamins, minerals and fiber ! Gluten itself doesn’t offer special nutritional benefits. Most commonly B vitamins, calcium, iron, , But the many whole grains that contain gluten do. magnesium, and fiber They’re rich in an array of vitamins and minerals, such as ! B vitamins and iron, as well as fiber. Most gluten-free alternatives, such as pasta and Studies show that whole grain foods, as part of a healthy bread, are significantly more expensive than diet, may help lower risk of heart disease, type-2 diabetes, and some forms of . their conventional counterparts The 2010 Dietary Guidelines for Americans recommends that half of all carbohydrates in the diet come from whole grain products. Pitfalls of Gluten- ! Iron Post-test free Diet ! Calcium ! Fiber ! Thiamin People who follow a gluten-free diet may ! Riboflavin have low levels of ! Niacin certain vitamins and ! Folate nutrients in their diets. ! Consider Multivitamin

Post-Test ANSWER: C

! 1. What is Gluten? ! 1. What is Gluten? A. An additive to many foods A. An additive to many foods B. A preservative B. A preservative C. A protein found naturally in certain foods C. A protein found naturally in certain foods D. A flavoring D. A flavoring

Gluten is a protein found in wheat, barley, and rye. These grains are processed and used as starches and binders in many processed foods. You can also find gluten in medicines, lip balms, and vitamins ANSWER: C

! 2. Which is a symptom of gluten intolerance? ! 2. Which is a symptom of gluten intolerance? A. Poor Circulation A. Poor Circulation B. Sore Throat B. Sore Throat C. Diarrhea C. Diarrhea D. Ringing in the ears D. Ringing in the ears

! Common symptoms of a gluten intolerance include diarrhea, cramping, bloating, gas, constipation, and anemia. Celiac disease, which is due to gluten intolerance and is an autoimmune disease, has many of the same symptoms. A unique rash called dermatitis herpetiformis affects 15% to 25% of people with celiac disease. The intensely itchy rash may show up on your elbows, knees, and buttocks.

ANSWER: D

! 3. Eating gluten-free is critical if you… ! 3. Eating gluten-free is critical if you… A. Want to lose weight A. Want to lose weight B. Want to cleanse your digestive tract B. Want to cleanse your digestive tract C. Want to have more energy C. Want to have more energy D. Have celiac disease D. Have celiac disease ! The only way to live symptom-free from celiac disease or a gluten intolerance is to always avoid foods with gluten. You may lose weight by eating gluten-free, but gluten-free doesn’t mean calorie- free. Eating fruits and vegetables is great, but make sure you’re getting all the nutrients necessary for a . ANSWER: B

! 4. There is no test for Celiac Disease ! 4. There is no test for Celiac A. TRUE Disease B. FALSE A. TRUE B. FALSE ! Screening can be done with blood work and if positive may be confirmed with an endoscopic biopsy.

ANSWER: D

! 5. Which grain does not contain gluten? ! 5. Which grain does not contain gluten? A. Rye A. Rye B. Barley B. Barley C. Wheat C. Wheat D. Quinoa D. Quinoa

! Quinoa is a “superfood” from the Andes Mountains that’s gluten-free and very nutritious, with high levels of protein and amino acids. It is an excellent, inexpensive alternative to grain. Quinoa may be eaten cooked like rice or couscous. It can also be ground into a flour. Some gluten-free pastas are made from quinoa flour. ANSWER: B

! 6. You can tell which prepared foods have ! 6. You can tell which prepared foods have gluten just by looking at them. gluten just by looking at them. A. TRUE A. TRUE B. FALSE B. FALSE

! There’s no way to tell by looking at cooked foods whether they are gluten-free unless they are plainly cooked meats, fish, or vegetables. Look out for things like breading or sauce -- especially cream sauce. Read the labels and ask questions. When in doubt, don’t eat it.

ANSWER: B

! 7. You can’t drink alcohol if you’re on a gluten- ! 7. You Can’t drink alcohol if you’re on a gluten- free diet. free diet. A. TRUE A. TRUE B. FALSE B. FALSE

! There’s no gluten in distilled spirits like wine and hard liquor. But some wine coolers and bottled mixed-liquor drinks have ingredients with gluten. Beer is made from grains that have gluten, but there are gluten-free beers on the market. ANSWER: B

! 8. Which is a good gluten-free ! 8. Which is a good gluten-free breakfast choice? breakfast choice? A. Toast with butter A. Toast with butter B. Scrambled Eggs and grits B. Scrambled Eggs and grits C. Bagel and cream cheese D. Pancakes C. Bagel and cream cheese ! Grits, which are made from corn, are gluten-free. Regular D. Pancakes bagels and pancakes made with wheat flour are a no-no, but gluten-free mixes are available. Unless it’s made with gluten-free bread, toast is off the breakfast menu.

ANSWER: C ! 9. Which department should you spend the ! 9. Which department should you spend the most time in when shopping for gluten-free most time in when shopping for gluten-free food? food? A. Frozen prepared foods A. Frozen prepared foods B. Snack food B. Snack food C. Produce C. Produce D. Cereal ! D. Cereal Fruits and vegetables are naturally gluten-free, so fill your grocery cart with as much as you want. Most frozen prepared , snack foods, and cereals contain gluten. ! Many supermarkets have gluten-free products like bread, cookies, cereals, and even frozen prepared foods in their health food section. ANSWER: B

! 10. Some parents believe eating gluten-free ! 10. Some parents believe eating gluten-free helps helps children with: children with: A. Dyslexia A. Dyslexia B. Autism Spectrum Disorder B. Autism Spectrum Disorder C. Hyperactivity C. Hyperactivity D. Tonsillitis D. Tonsilitis ! Some parents of children with Autism Spectrum Disorder believe their child’s behavior gets better if they eat gluten- free, but researchers disagree. ! One study showed that putting children with ASD on a gluten-free, casein-free diet didn’t significantly affect their sleep or behavior difficulties.

ANSWER: A

! 11.Which snack is off-limits on a gluten –free ! 11.Which snack is off-limits on a gluten –free diet? diet? A. Pretzels B. Tortilla chips A. Pretzels C. Rice cake B. Tortilla chips D. Popcorn C. Rice cake D. Popcorn ! Unless they are labeled gluten-free, most pretzels are made with wheat flour. But cheer up: There are several brands of gluten-free pretzels. There are other snacks like tortilla chips (made from corn), rice cakes (the unflavored kind), some potato chips, and popcorn. Make sure to read the label. ANSWER: B

! 12. Which restaurant entrée is a good gluten- ! 12. Which restaurant entrée is a good gluten- free choice? free choice? A. Chicken Parmesan A. Chicken Parmesan B. New York Strip B. New York Strip C. Fried Shrimp C. Fried Shrimp D. Fajitas D. Fajitas A. Chicken Parmesan

! The simpler the food choice the better. Don’t forget to ask about a gluten free menu.

Sources of more information Any Questions

! http://Celiac.org ! www.eatright.org