Vandna Jerath, MD discusses gluten: fads vs. facts and the impact on your health for the Women's Health & Wellness Expo for Parker Adventist Hospital at the Parker PACE Center. Learn about gluten, celiac disease, gluten sensitivity, a gluten free diet, and evolving gastroenterology (GI) research.

1. Vandna Jerath, MD, FACOG
Women’s Health & Wellness Expo | PACE Center | Parker Adventist Hospital
drjerath.com
optimawomenshealthcare.com
October 3, 2014

2. FACOG – Board-Certified
Private practice – 16 years
Full scope obstetrics & gynecology
Enjoy education and community outreach
Disclosures – no affiliations
Healthcare social media expert
drjerath.com
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

3. General Ob/Gyn Services
Women’s health resource/expert
Female empowerment
◦Be educated  Be engaged  Be empowered
Spa-like setting
Individualized, personalized, and compassionate care
optimawomenshealthcare.com
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

4. To understand what gluten is and the impact it has on health.
To learn about celiac disease including prevalence, signs/symptoms, diagnosis, and management.
To understand the evolving spectrum of gastroenterological conditions, particularly regarding gluten and gluten sensitivity.
To understand the dietary restrictions of a gluten free diet.
To be able to sort out the health vs. hype regarding gluten.
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

5. Jimmy Kimmel video
◦http://www.youtube.com/watch?v=AdJFE1sp4Fw
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

6. What is all the fuss?
◦Less people eating gluten
◦Revenue producing for the food industry
◦Potentially life threatening for people with celiac disease
May cause GI symptoms
◦Allergy vs. intolerance
Diet fad
Why?
◦GMO crops?
Possible overdiagnosis and overtreatment
Media stories
◦NY Times blog article – 9/29/2014
◦Celiac Disease, a Common, but Elusive, Diagnosis
◦http://well.blogs.nytimes.com/2014/09/29/celiac-disease-diagnosis- gluten/?_php=true&_type=blogs&_r=0
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

7. Protein found in grains
◦Wheat, barley, and rye
◦Gliadin peptides
Found in common foods
◦Cereal
◦Bread
◦Baked goods
◦Pasta
◦Battered and possibly fried foods
◦Malt
◦Sauces, marinades, salad dressings, soy sauce, gravy
◦May be hidden in processed foods
◦Preservatives
◦Beer
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

8. Natural, plain, or unprocessed foods
◦Meats/Poultry/Fish
◦Fruits
◦Vegetables
◦Beans
◦Dairy
◦Nuts
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: M. Dennis, S. Case, 2008 as appeared in Practical Gastroenterology, April 2004 and BIDMC presentation by Daniel Leffler, MD, MS and Melinda Dennis, MS, RD, LDN.

9. Safe grains, starches, & flours
◦Rice
◦Corn
◦Soybeans
◦Tapioca
◦Potato
◦Quinoa
◦Millet
◦Flax
◦Arrowroot
◦Amaranth
◦Buckwheat
◦Sorghum
◦Millet
◦Teff
◦Nut flours (almond, pecan)
◦Seed flours (sesame)
◦Legume flours(garbanzo, lentil)
◦Bean flours
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: M. Dennis, S. Case, 2008 as appeared in Practical Gastroenterology, April 2004 and BIDMC presentation by Daniel Leffler, MD, MS and Melinda Dennis, MS, RD, LDN.

10. Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: Thompson T. Celiac Disease Nutrition Guide, 2nd ed. Chicago: American Dietetic Association; 2006.
Allowed Foods
amaranth arrowroot buckwheat cassava corn flax Indian rice grass Job's tears
legumes millet nuts potatoes quinoa rice sago
seeds sorghum soy tapioca teff wild rice yucca
Foods To Avoid
•wheat including einkorn, emmer, spelt, kamut
•wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein
barley rye triticale (a cross between wheat and rye)
Other Wheat Products
bromated flour durum flour enriched flour farina
graham flour phosphated flour plain flour
self-rising flour semolina white flour
Processed Foods that May Contain Wheat, Barley, or Rye*
bouillon cubes brown rice syrup candy chips/potato chips cold cuts, hot dogs, salami, sausage communion wafers
French fries gravy imitation fish matzo rice mixes sauces
seasoned tortilla chips self-basting turkey soups soy sauce vegetables in sauce
The Gluten-free Diet: Some Examples
In 2006, the American Dietetic Association updated its recommendations for a gluten-free diet. The following chart is based on the 2006 recommendations. This list is not complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten.

11. Digestive disease that damages small intestine
◦Damaged villi of the small intestine
◦Malabsorption of nutrients
◦Celiac disease (CD), Celiac sprue, nontropical sprue, gluten-sensitive enteropathy
Autoimmune reaction
Intolerance to gluten
◦How does it start?
◦Surgery, infection, cereal < 3mo age, hereditary?
Prevalence 1 in 100
Women > Men
◦2/3 of current diagnosis are female
More common in Caucasians
Genetic (5-10% first degree relative)
May take 10 years or more for diagnosis
◦Average age of diagnosis is 50
◦Confusing symptoms
17% of Americans don’t know they have the disease
Lifelong gluten free diet is the only treatment
◦Less than 20ppm
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006; 131:1977-1980.
Source: Celiac Disease. NIH Publication No. 08-4269. September 2008.

12. Husby, S. & Murray, J. A. (2014) Diagnosing coeliac disease and the potential for serological markers
Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2014.162

13. Abdominal bloating
Abdominal pain
Chronic diarrhea
Vomiting
Constipation
Stool abnormalities
◦Pale, foul-smelling, fatty
Weight loss
Irritability
Malabsorption
Fatigue
Joint pain
Muscle pain
Osteopenia/Osteoporosis
Iron-deficiency anemia
Tingling in hands/feet
Headaches
Abnormal menses
◦Infertility
◦Recurrent miscarriage
Canker sores
Skin rash - itchy
◦Dermatitis herpetiformis
◦Dapsone treatment
Cognitive impairment – brain fog
Ataxia
Automimmune diseases
◦Thyroid disease
◦Rheumatoid arthritis
◦Type 1 diabetes
◦Sjogren’s syndrome
◦Addison’s disease
◦SLE (lupus)
Non Hodgkin’s Lymphoma
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006; 131:1977-1980. Source: Celiac Disease. NIH Publication No. 08-4269. September 2008.

14. Must be on a gluten diet for testing
Blood tests
◦IgA tissue trans-glutaminase antibodies (tTG)
Most efficient single serologic test
◦IgA/IgG deaminated gliadin peptide antibodies (DGP)
Genetic testing
◦Human leukocyte antigen (HLA) haplotypes
◦DNA PCR
◦HLA DQ2 (95%)/DQ8 (5%)
No celiac if these are negative
Intestinal biopsies
◦Multiple biopsies
◦Histological testing for villous atrophy
◦Gold standard for diagnosis
Skin biopsies
Equivocal test results can occur
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006; 131:1977-1980

15. Consultation with a skilled dietitian
Education about the disease
Lifelong adherence to a gluten free diet
Identification and treatment of nutritional deficiencies
Access to an advocacy group
Continuous long-term follow-up by a multidisciplinary team
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: NIH Consensus Development Conference on Celiac Disease.

16. Is there a spectrum of disease?
Non-celiac gluten sensitivity (NCGS)
◦First described in 1980’s now “re-discovered”
GI symptoms responsive to a gluten free diet
◦May be able to titrate their gluten exposure to avoid symptoms
Prevalence unclear
◦Many people self-diagnose and start a gluten free diet without medical consultation (not recommended)
◦.5-6% based upon different studies
◦More common in females
Transitory or permanent?
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: Fasano A, et al. Non-celiac gluten sensitivity: the new frontier of gluten related disorders. Nutrients. Oct 2013; 5(10): 3839-3853

17. Diagnosis
◦Difficult to distinguish from irritable bowel syndrome (IBS) or wheat allergy (WA)
◦Lack of biomarkers for diagnosis
First generation IgG AGA – 7.7%
HLA DQ2/DQ8 – 50%
◦Different histological changes on intestinal biopsy
Present
◦Younger age (case reports in children)
◦Lack autoimmune or family history
◦Constipation
Less likely to be at risk
◦Malabsorption
◦Severe nutrient deficiencies
◦Lymphoma
◦No major complication if untreated
Evolving spectrum
◦Some more like celiac disease
◦Some more like food allergy
◦Is GMO wheat contributing?
◦Possible relationship to autism and schizophrenia
◦May be related to wheat amylase-trypsin inhibitors
◦May be related to low-fermentable, poorly absorbed, short chain carbohydrates
Reduced FODMAPs (fermentable oligo-, di-, and mono-saccharides and polyols) diet
Fructans, galactans, fructose, and polyols
Women’s Health & Wellness Expo | PACE Center | 10/3/2014
Source: Fasano A, et al. Non-celiac gluten sensitivity: the new frontier of gluten related disorders. Nutrients. Oct 2013; 5(10): 3839-3853.

18. Nonceliac enteropathy (NCE)
◦Can mimic celiac disease
◦May cause villous atrophy
◦Can respond to a gluten free diet
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

19. Challenges
◦Cross-contamination
◦Hidden ingredients
◦Preservatives
Wheat free is not gluten free
Not necessarily low fat or for weight loss
Avoid
◦Wheat
◦Malt
◦Modified food starch
◦Dextrin
◦Hydrolyzed wheat protein
DO NOT START w/o confirming or ruling out celiac disease
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

20. Fads
◦It is a good weight loss diet.
◦Will make you “sick” or “fat”.
◦GI symptoms will definitely occur.
◦Healthy for you.
◦Everyone is doing it.
◦Ok to start a gluten free diet without a diagnosis.
Facts
◦People with celiac disease have a permanent lifelong intolerance and cannot eat gluten.
◦May cause an autoimmune response with GI symptoms.
◦Some people may have an allergy or sensitivity.
◦Gluten free diet may improve sensitivity symptoms.
◦Medical information and evidence is evolving.
◦Do not start a gluten free diet without a medical diagnosis or consultation.
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

21. Americanceliac.org
Celiac.com
Celiac.org
Celiaccentral.org
Csaceliacs.org
Eatright.org
Gluten.net
Glutenfreedrugs.com
Healthyvilli.org
NIH – http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/
Reallifewithceliacdisease.com
Women’s Health & Wellness Expo | PACE Center | 10/3/2014

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Women’s Health & Wellness Expo | PACE Center | 10/3/2014

23. Vandna Jerath, MD
Optima Women’s Healthcare
Sierra Medical Office Building
Parker Adventist Hospital Campus
9399 Crown Crest Blvd, Suite 450
Parker, CO 80138
303.805.1807 P | 303.595.5390 F
optimawomenshealthcare.com
drjerath.com
Email - staff@optimawomenshealthcare.com
Slides – http://slideshare.net/VandnaJerathMD
Women’s Health & Wellness Expo | PACE Center | 10/3/2014