9/16/13

Gluten free diet will make you lose weight, increase your sexiness, and save your soul!
(and make you obese &poor)!

NST10, Chris Vulpe, Fall 2013!

Gluten Free Craze!

Poll of 200 dieticians by PR firm Gluten free most popular approach to weight loss for 2013

Read more: http://business.time.com/2013/03/13/why-were-wasting-billions-on-gluten-free-food/#ixzz2eiYy5Bpy

9/16/13

Aug 2012 Packaged Fact consumer survey! !Why are you buying gluten free?! ! Respondants! 35% - generally healthier! 27% - manage my weight! 21% - generally low carb! 15% - said have gluten intolerance! 7% - said they have Celiac Disease! Seth Rogen discusses Gluten Free

Gluten Free is big business Products with Gluten free claims 2007- ~600 2011 - ~1600 4.2 billion in the US this year ! Projected to be $6 billion revenue by 2018! double digit growth rate of 10.2% !
The most important factor behind buying more gluten-free food products is that they are considered healthier than conventional products. Other important factors are growing retail presence and continual improvements in new gluten-free products development. One of the major restraints of the gluten-free products market is a lack of awareness. Many consumers do not know the difference between an allergy and intolerance. Furthermore, many consumers are either misdiagnosed or undiagnosed entirely for the coeliac disease.
Gluten-Free Products Market By Type (Bakery & Confectionery, Snacks, Breakfast Cereals, Baking Mixes & Flour, Meat & Poultry Products), Sales Channel (Natural & Conventional) & Geography -Global Trends & Forecasts To 2018"
http://www.foodmanufacturing.com/news/2013/07/consumer-trends-gluten-free-market-experiencing-double-digit-growth http://www.foodnavigator.com/Financial-Industry/Gluten-free-taste-improvements-spur-market-growth

9/16/13

!! Current labeling by companies is not regulated ! !! FDA issued a ruling 8/13 on labeling which must be used by 8/14 ! !! < 20 ppm of gluten (current detection limit)! !! Does not contain an ingredient that is any type of wheat, rye, barley, or crossbreeds of these grains! !! Does not contain an ingredient derived from these grains and that has not been processed to remove gluten! http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm363069.htm !

$$

Gluten Free is expensive!

$$

!! The price of 56 ordinary grocery items that contain gluten were compared with their gluten-free counterparts. ! !! All of the gluten-free ones were more expensive, and some were much more expensive! !! On average glutenn-free products were 242% more expensive than the gluten-containing versions. !
Can J Diet Pract Res. 2008 Fall;69(3):147-50. Gluten-free and regular foods: a cost comparison. Stevens L, Rashid M.
http://business.time.com/2013/03/13/why-were-wasting-billions-on-gluten-free-food/#ixzz2eiZBZywV

9/16/13

What the heck is Gluten?!

!"#$%&'()'*'+,-$%(&'$.*$' /(0%)'1-#/.'%"*)23($4' 5.(3.'*""-5)'($'$-',()%' 5($.-#$'3-""*+)(&/'5.("%' $,*++(&/'$.%'678'''

Gluten in wheat and related plants!

9")-'(&'5.%*$'1%,(0*20%):' ;#"/*,<'3-#)3-#)<'=*$*>*<' )%($*&<')%=-"(&*<'$,(23*"%<')+%"$<' ?*=#$<'%(&?-,&<'%==%,'*&1' *&4$.(&/'5($.'5.%*$'(&'$.%' 2$"%'@%A3%+$';#3?5.%*$

9/16/13

Why would anyone go gluten free anyway?!

Gluten related Disorders

Wheat Allergy Allergy

Celiac Disease Autoimmune Disorder

Non-Celiac Gluten Sensitivity ?

Can remit with age

Lifelong

!! Wheat allergy allergic reaction to wheat duh!! !! Symptoms mild (rash, hives, itching, swelling) to severe (breathing difficulties, wheezing, anaphylaxis) ! !! Pathophysiology IgE mediated food allergy! !! Usually onset in childhood and resolves by adulthood! IgE on surface of Mast cells bind the allergen mast cells release histamines and host of additional inflammatory mediators. ! IgE and mast cells in allergic disease Nat Med 18(5): 693704. 2012

Wheat Allergy!

Histamines & more

9/16/13

Celiac Disease is an Auto-immune disorder!

!! What?! !! Who? ! !! When?!
!! Highly diverse presentations. ! !! Common in many ethnic backgrounds!

!! Any age after gluten ingestion! !! Average 11 years of symptoms prior to diagnosis! !! Average age at diagnosis ~45 yrs! !! How?! !! Autoimmune disorder due to combination of genetic predisposition, environmental factors, and immune dysregulation!
Green AJG 2001, Cranney DDS 2007

Celiac Disease Signs and Symptoms

! No classic signs! ! Bloating, abdominal pain, diarrhea! ! Less noticeable symptoms!
! Anemia, joint pain, stomach pain, ! ! irritability, dental or bone disorders, ! ! weight loss, stunted growth in kids!

! Can imitate symptoms of other ! conditions such as irritable bowel! ! Dermatitis herpetiformis! ! Silent Celiac Disease !
! No symptoms, still damage!

9/16/13

Celiac Disease affects small intestine

Celiac disease damages! the small intestine!

Healthy Villi

Flat Villi

Disrupted ! Nutrient ! Uptake in! Celiac Disease!

9/16/13

Pathophysiology of Celiac Disease!

Disrupted intestinal nutrient uptake!

9/16/13

Celiac Disease and Obesity

!! BCDE'4%*,)'*F%,'/"#$%&GH,%%'1(%$'' !! I-#;"%'$.%'J'-H'-0%,5%(/.$'+*,23(+*&$)'' !! K#$,(2-&*"'(=;*"*&3%'-H'/"#$%&GH,%%'H--1)'

!! L%+"*3%'/"#$%&'3*,;-.41,*$%)'5($.''H*$<'+,-$%(&<'.(/.' 3*"-,(%';%0%,*/%)'*&1'*'1%3,%*)%'(&'M;%,''
6%"(*3'I()%*)%'*&1'7;%)($4:'K%%1'H-,'&#$,(2-&*"'H-""-5G#+'*F%,'1(*/&-)()<'Eur J Clin Nutr. 2010 Nov;64(11):1371-2.

70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

In 679 celiac patients:

At Diagnosis On GFD

At diagnosis: 32% overweight or obese (compared to 59% in regional population) On Gluten Free Diet : ! Mean BMI increased from 24.0 to 24.6 ! 22% with normal or high BMI at diagnosis increased BMI by >2 points ! 15.8% became overweight ! 22% overweight at diagnosis 18! gained additional weight

Aliment Pharmacol Ther. 2012 Mar;35(6):723-9.

9/16/13

Celiac disease prevalence is increasing

!! N%O%,'I(*/&-)()'
!! P=+,-0%1'1(*/&-)23)'=*4' '(&3,%*)%',%3-/&(2-&'-H'1()%*)%'

TTG blood test (Tissue TransGlutaminase)

!! Q4/(%&%'Q4+-$.%)()'
!! 6#,,%&$'%&0(,-&=%&$'$--'3"%*&'' !! P1"%'(==#&%')4)$%='*O*3?)'#)'
Causes of Death in People With Celiac Disease Spanning the Pre- and PostSerology Era: A Population-Based Cohort Study From Derby, UK Am J Gastroenterol 2011; 106:933939;

!! 8R)$'6%&$#,4'I(%$'
!! S,-3%))(&/'-H'H--1'.*)'3.*&/%1'' 5.(3.'"%*1)'$-'/,%*$%,'(==#&%'*320*2-&)'

!! T-1%,&'5.%*$'

' '

!! Q4;,(1(>*2-&'-H'5.%*$'0*,(%2%)'U' ''''=-,%'(==#&-/%&(3'

!! Gluten contained in wheat, rye, barley

!! Triticale, kamut, spelt, semolina, farina, einkorn, bulgur, and couscous !! Malt made from barley
!! Malt syrup, malt extract, malt flavoring, malt vinegar !! Beer, whiskey

Treatment for celiac disease No Gluten!!

!! Food additives
!! Soy sauce, carmel color, bouillon, modified food starch !! Mono or diglycerides, emulsifiers, vegetable protein

!! Processed foods
!! Sausage, luncheon meat, gravies and sauces !! TV dinners, pot pies

10

9/16/13

Non-Celiac Gluten Sensitivity (NCGS)

! Clinicians reporting increasing incidence unexplained gastrointestinal and other symptoms by patients attributed to gluten.! ! These patients have frequently placed themselves on a Gluten Free Diet (GFD) after negative experiences from eating glutencontaining foods and report significant improvements on a GFD.! NCGS Symptoms : ! ! Gastrointestinal! ! ! abdominal discomfort, bloating, pain, or diarrhea! ! Extra-intestinal! ! headaches, foggy mind, depression, fatigue, musculoskeletal pains, and skin rash!
Neurogastroenterol Motil. 2013 Aug 12. Non-celiac gluten sensitivity: clinical relevance and recommendations for future research.

Diagnosis of NCGS!
! Non-Celiac so negative for diagnostic tests for CD ! No antibody test ! No evidence of intestinal atrophy ! Primarily self report ! improved symptoms after GFD ! worse symptoms after gluten diet ! concern about placebo and nocebo effect ! Double blind placebo gluten diet ! Unclear if represents single entity Ann Intern Med. 2012;156(4):309-

11

9/16/13

! Popular press have suggested that 17 million gluten sensitive (Washington Post; 29 April 2011)!
(Gluten-sensitive diarrhea without evidence of celiac disease. Gastroenterology.1980; 79: 8016.)!

Incidence and GFD Rx of NCGS!

! In 1980, nine of 17 patients experiencing abdominal discomfort and diarrhea reported amelioration of symptoms on GFD but had no evidence of CD. ! In 2000, a study of 94 adults affected by abdominal symptoms after cereal ingestion ! overt CD of 9%, 8% with latent CD, 20% with cereal allergy, 63% not CD nor allergic but reported better symptoms on GFD! ! In 2010, non-celiac gluten sensitivity was reported at 6% in secondary care GI clinic (347 of 5896)
(Intolerance to cereals is not specific for coeliac disease. Scand J Gastroenterol 2000; 35: 9426.)! nomenclature and classification. BMC Med 2012; 10: 13.)! (Spectrum of gluten-related disorders: consensus on new

! In 2012, 0.5% prevalence of NCGS based on analysis of population based survey (NHANES) which identified individuals on GFD without CD diagnosis!

(Prevalence of gluten-free diet adherence among individuals without celiac disease in the USA: results from the Continuous National Health and Nutrition Examination Survey 20092010. Scand J Gastroenterol 2013;48: 9215.)!

GFD reported to improve symptoms!

! GFD may improve GI symptoms in a some patients ! !Three small un-blinded studies (26, 41, 45 patients)!
! ! !

! Modest improvements (e.g. decrease stool frequency from 2.6 to less than 2 per day)!

Celiac disease-like abnormalities in a subgroup of patients with irritable bowel syndrome. Gastroenterology 2001; 121: 132938.! Predictors of clinical response to gluten-free diet in patients diagnosed with diarrhea predominant irritable bowel syndrome. Clin Gastroenterol Hepatol 2007; 5: 84450! A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: effects on bowel frequency and intestinal function. Gastroenterology 2013; 144: 90311,

12

9/16/13

Best evidence for and against NCGS by same research group!!

First study reported in 2011
double-blind (neither researcher nor patient knows diet content)

Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial.Am J Gastroenterol 2011; 106: 50814

Second Study Just Reported!

!

Reproducibility in change! in overall symptom severity!

Rechallenge is key difference Gluten did not cause return of symptoms !

No Effects of Gluten in Patients With Self-Reported Non-Celiac Gluten Sensitivity After Dietary Reduction of Fermentable, Poorly Absorbed, Short-Chain Carbohydrates GASTROENTEROLOGY 2013;145:320328

13

9/16/13

NCGS fad or disease?!

!! More study and evidence is needed ! !! Celiac disease is increasing! !! ?Could increasing reports of NCGS be related?! !! Identification of diagnostic marker would increase confidence in disorder! !! Possibly multiple causes?! !! Could be both a fad and a real disease! !! Good time to be Quinoa grower! !

"!Celiac Sprue Association of the USA!

www.csaceliacs.org! www.celiac.org!

Resources!

"!Celiac Disease Foundation! "!Gluten Intolerance Organization!

www.gluten.net!

"!National Foundation for Celiac Awareness!

www.celiacawareness.org !

14