21/07/2020 Is ‘Gluten Free’ really 100% Gluten Free? Why it matters Dr. Kim Faulkner-Hogg Dietitian, Advanced APD BSc, Post Grad Dip Nut & Diet, PhD [email protected] http://www.glutenfreenutrition.com Brought to you by 1 Talk Overview: Gluten ▪ Coeliac Disease & Non-Coeliac Gluten Sensitivity (NCGS) ▪ Defining gluten 3 ways ▪ Gluten digestion ▪ Tests to measure background gluten in a gluten free diet ▪ Accidental and contaminant gluten quantified ▪ Toasters, pastas and cakes with shared cooking equipment ▪ In supermarket and restaurant foods ▪ Impact on Quality of Life ▪ Non-Diet therapies to combat contamination ▪ Enzyme therapies to break down undigested gluten ▪ Proposed role alongside the gluten-free diet. ▪ Dietitians role ▪ Points & resources to reduce background gluten exposure 2 1 21/07/2020 Who is avoiding wheat or gluten? 28% of Australians monitor their gluten intake 1 ▪ 4 % avoid it all together Coeliac Disease: ▪ 1 in 80 males and 1 in 60 females in Australia1 ▪ Villi damage and symptoms ▪ Lifelong avoidance of all gluten Non-Coeliac Wheat/Gluten Intolerance ▪ Common: 11 %2 ▪ Symptoms vary over time ▪ Varying avoidance of possible wheat triggers2 ▪ Gluten ▪ Fructans ▪ Lectins ▪ Amylase/trypsin inhibitors 3 Defining Gluten 1. Bakers definition: 2. Todays definition: Gluten:- is the elastic substance that Gluten:- is the causative agent for forms when water is added to villi damage in those with coeliac flour….which stretches and traps disease. gas….allowing the product to rise and be light and porous. 4 2 21/07/2020 GLUTEN Containing Grains ▪ Wheat (Spelt, Atta, Durum, Burghul, Khorasan) ▪ Triticale (Hybrid of wheat and rye) ▪ Rye (Pumpernickel) ▪ Barley Listed in decreasing order of gluten quantity ▪ Possibly oats: controversial 5 WHEAT STARCH 3. How Science Defines Gluten ~<0.02 % gluten PROTEIN Water ALBUMINS Sodium Chloride GLOBULINS Ethanol WHEAT PROLAMIN (Gliadin) GLUTEN ω GLUTELIN (Glutenin) 6 3 21/07/2020 Amy C Brown (2012) Expert Review of Gastroenterology & Hepatology, 6:1, 43-55, DOI: 10.1586/egh.11.79 7 How Coeliac Disease Defines Gluten 1940’s Dr. Willem-Karel Dicke, discovered that something in the gluten portion of the wheat grain caused villi destruction in those with coeliac disease Today the definition of gluten is synonymous with the physiological damage seen in coeliac disease 8 4 21/07/2020 What is Gluten? Proline Glutamine Gluten Protein Gluten is a protein Proteins are strings of amino acids Amino acids are linked together in different repeating patterns Glutenin Gliadin Gluten containing grains, that can cause damage, have a high proportion of proline and glutamine amino acids in the prolamin portion 9 Picture from: Alessio Fasano. Sci Am. 2009 Aug;301(2):54-61. Surprises from celiac disease. 10 5 21/07/2020 Gluten Digestion Gluten After consumption It is divided into Glutenin Gliadin GIP: Gluten Immunogenic Peptide ▪ Remains toxic to the gut in some Enzymes in our gastrointestinal track digest proteins into peptides and single amino acids Peptides 11 SHUT SHUT Enterocytes Small intestine – Digested food Pass through SHUT Inside the lining of the small intestine Bloodstream 12 6 21/07/2020 Enterocytes Small intestine – Digested food Intestinal damage TTG Inside the lining of TTG the small intestine TTG Bloodstream 13 Coeliac Disease Gluten Ingestion Symptoms Diagnoses CD Raised coeliac-specific blood antibodies Inflamed small intestinal mucosa: Villous atrophy Strict Gluten Free Diet (20ppm) Restoration of Health3 ▪ ↓ symptoms ▪ ↓ antibodies ▪ Villi recovery 14 7 21/07/2020 Gluten Free Internationally The term gluten free defines a quantity of gluten that is thought to do no harm While the details of the standards differ4 <20ppm United States, Canada and Europe + gluten free oats 20mg gluten/1kg of food <10ppm Argentina + no oats 10mg gluten/1kg of food <3ppm Australia, New Zealand and Chile + no oats 3mg gluten/1kg of food 15 Coeliac Disease Recovery Gluten Free Diets before the year 2000 5,6,7,8,9 ▪ daily gluten intake between 5-150mg ▪ Wheat starch people Number of of Number 0mg 2mg 10mg 30mg 50mg (aim for <20ppm) Potential small bowel damage Mg gluten/day 16 8 21/07/2020 Coeliac Disease Recovery 10mg gluten daily9 ▪ Generally safe for those with CD ▪ International Food Standard aim Regular ingestion of 50mg daily9 ▪ Leads to damage of the small bowel people Number of of Number 0mg 2mg 10mg 30mg 50mg (aim for <20ppm) Potential small bowel damage Mg gluten/day 17 Coeliac Disease Recovery 10mg gluten daily9 ▪ Generally safe for those with CD Biopsy ▪ International Food Standard aim ≤7mg gluten 9 people Regular ingestion of 50mg daily per day10 Number of of Number ▪ Leads to damage of the small bowel Symptoms 0.15mg gluten There is a high variability of per day10 sensitivity among those with coeliac disease 0mg 2mg 10mg 30mg 50mg (aim for <20ppm) Potential small bowel damage Mg gluten/day 18 9 21/07/2020 Gluten Quantities Using the figure of ~2.5g gluten in a slice of wheat bread (=2,500mg gluten) ~50mg gluten = 1/50 of a slice of wheat bread 50 ~400-500 mg 19 Gluten Quantities ~ 2.5 g gluten in a slice of wheat bread Average gluten intake on 20 ppm GFD 10 is 66 – 108 mg gluten/day ~ 10 mg gluten = 1/250 slice of bread Several crumbs ≡ 6 -10 mg gluten 20 10 21/07/2020 Recovery of Coeliac Disease Stats vary from paper to paper Villi ▪ Most suggest between 30-50% of patients have ongoing villi damage on a GFD 11,12,13,14,15 ▪ Slow recovery ▪ 4-15% were not recovered at 5 years16,17,18 Symptoms ▪ Despite adherence, there is a high rate of GI symptoms in people on GFD’s 19 . ▪ 25-40% of patients have ongoing symptoms despite the GFD20,21,22 ▪ Generally those diagnosed as kids have the best outcomes Probably from trace sources of gluten 21 Adherence to a GFD Adherence to the GFD varies from 36-96%23 New tests: detect Gluten Immunogenic ▪ Demographic Peptides in faeces and urine ▪ Psychosocial ▪ Clinical factors Made the theory of background gluten a reality Adherence has 2 main components ▪ Deliberate choice to eat a gluten product GIP ▪ Inadvertent ingestion of gluten ▪ Trace backwards and find the gluten ▪ Background contamination 22 11 21/07/2020 GIP Detection Kits Morenos’ 2017 study reports11 GIP: Gluten Immunogenic peptides ▪ GIP’s can be detected in urine ▪ Make it through the intestine unabsorbed ▪ 4-6 hours after ingesting gluten ▪ Excreted in stool and urine ▪ Remain detectable for 1-2 days 50% of the study group Developing tests to measure this suggest…. ▪ Had positive urine GIPs ▪ Stool: ▪ Detects gluten intakes greater than 40mg/day Patients with no villi damage: ▪ Could be positive ~2-7 days after ingestion ▪ 89% had negative urine GIPs ▪ Detects a more chronic exposure ▪ Urine: Patients with villous damage ▪ Detect from about 40-500mg of gluten /day ▪ All had detectable urine GIP’s ▪ Detects a more accurate exposure 23 GIP Detection Kits Syage 2018 study reports 24 ▪ Background gluten ingestion on a GFD was ▪ Between 200-400mg gluten/day ▪ Moderate symptoms :- significantly more than 200mg/day More research is needed to define ▪ Cut off points ▪ Conversion factors to gluten consumed ▪ Potential gut microbiota influences on GIPs ▪ Best uses 24 12 21/07/2020 Uses for the GIP test Caution with use as they could create anxiety Do not want people to use them after eating at restaurants to say ▪ You glutened me!!! ▪ Socially and emotionally damaging leading to isolation Useful in refractory CD if obvious gluten has been excluded ▪ measure if background gluten could be a contributing factor Research clinical trials ▪ Measure compliance 25 Typical Western Diet 10-20g gluten/day25 (ie 10 000- 20 000 mg) 26 13 21/07/2020 Accidental & Inadvertent Gluten Ingestion May be a reason for symptoms and villi damage Some potential sources of contamination of gluten free foods Hidden in Foods26 Farm, Factory & Market Kitchen/Restaurant/Take-away Soy sauce Share transport trucks with wheat Self-serve buffets Beer battered chips Share storage facilities with wheat Toasters Boost low protein flour Share equipment with wheat Chopping Boards Salad dressing Unlabelled fresh food Shared cupboard & fridge space Thickeners Open bulk container foods Shared food crumbs:-jam, butter Imitation crab Self serve outlets Shared food preparation areas Gravies and marinades Ambiguous food labels Knives Confectionary Pasta colanders Pharmaceutical tablets 27 Contamination Potential Weisbrod V et al. Gastroenterology 2020 Jan;158(1):273-275. doi: 10.1053/j.gastro.2019.09.007 28 14 21/07/2020 Contamination Summary27 ▪ Shared pop-up toasters OK ▪ Be wary of GF pasta and GF cut cakes ▪ Restaurants ▪ School fetes OVERALL Cross contamination when cooking is not a huge risk for most people 29 Food labelled Gluten Free Gluten Free in Gluten Free Not Gluten Free Australia Internationally Country Ref # of products Under 5ppm <20ppm Over 20ppm n (%) n (%) n (%) Canada Gelinas 2008 28 77 70 90% 7 9% Canada Koerner 2013 29 268 265 99% 3 1% Europe Gibert 2013 30 205 193 94% 10 with detectable gluten USA Sharma 2015 31 275 265 96% Australia Forbes & Dods 169 imported GF 169 100% Not R5-Eliza 2016 32 foods Italy Verma 2017 33 93 91 98% 2 2% 30 15 21/07/2020 Gluten free by ingredient but not labelled Gluten Free Gluten Free in Gluten Free Not Gluten Free Australia Internationally Country Ref # of products Under 5ppm <20ppm Over 20ppm n (%) n (%) n (%) Finland Collin 2004 34 59 46 75% 13 22% Canada Gelinas 2008 28 71 55 74.5% 16 22.5% USA Thompson 2010 35 22 15 68% 7 32% USA Sharma 2015 31 186 138 74% 12 6% 36 19%