Professional Documents
Culture Documents
Where Is The Wheat
Where Is The Wheat
Answer:
Everywhere
Perspectives
Compare to
Rheumatoid arthritis (~1% of Americans)
Epilepsy (~1% of Americans)
Diabetes type 1 and 2 (8% of Americans)
Type 1 diabetes effects ~2 million Americans
www.mayoclinic.com/health/medical/IM02906
Pathophysiology
Autoimmune disorder with environmental
trigger
Abnormal response to gluten protein
Genetic component
Occasional triggers
Infection
Physical injury or surgery
Pregnancy
Severe stress
Clinical Presentation
Classic gastrointestinal symptoms
Chronic diarrhea 45-85%
Fatigue 78-80%
Abdominal pain and bloating 34-64%
Weight loss or low weight 45%
Constipation 12-38%
Vomiting 5-16%
Latent
Previous celiac diagnosis that responded to
management; then asymptomatic with normal diet
May have positive serology
Normal mucosa
Progresses to celiac disease over time
Complications
Differential Diagnosis
Review of Systems
Gastrointestinal
Skin
Reproductive
Neurological
Endocrine
Psychological
Pediatric History
Records from pediatrician
History including particularly
Failure to thrive
Diagnoses considered in past
Pertinent labs
Growth chart
Family History
Celiac disease
Other intestinal diseases
Autoimmune diseases
Thyroid disease
Diabetes
Genetic syndromes
Physical
Height; weight; vital signs
General
Skin
HEENT
Abdomen
Musculoskeletal
Neurological
Gynecological
Laboratory studies
Bloodwork
Anti-tissue transglutaminase (tTG) antibodies
Endomysial antibodies (EMA)
Deamidated gliadin peptide (DGP) antibody
Antigliadin antibodies (AGA) not as accurate
Nutritionist
Student
Family/Friends
Food Services
Genetic Counselor
Clinical follow-up
Consider the whole patient
Observe for change in symptoms over time
Evaluate for possible complications of
disease
Supplement to address vitamin and
mineral deficiencies
Follow-up no specified timeline
Review knowledge of celiac disease
Re-assess lab values
Reinforce management of gluten-free lifestyle
Patient Education
Determine level of understanding
Disease process
Complications and risks
Benefits of following a restrictive diet
Support Groups
Local
On campus / City / Region
National
Celiac Disease Foundation www.celiac.org
The Gluten Intolerance Group www.gluten.net
Online
National Foundation for Celiac Awareness
www.celiaccentral.org/college
Celiac Disease Awareness Campaign
www.celiac.nih.gov
Social media
Educational Materials
Selected Pamphlets
Navigating the gluten free diet in college
www.celiaccentral.org/college
What I need to know about celiac disease
www.digestive.niddk.nih.gov
Gluten-free diet guide for families
www.naspghan.org
Selected Magazines
Gluten-Free Living www.glutenfreeliving.com
Living Without www.livingwithout.com
Selected Books
Celiac Disease: A Hidden Epidemic by
Peter Green and Rory Jones
The First Year: Celiac Disease And Living
Gluten-free by Jules Shepard
Gluten-Free Diet: A Comprehensive
Resource Guide by Shelley Case
Real Life with Celiac Disease by Melinda
Dennis
Nutrition Outline
Gluten free diet (basics and hidden
sources)
Review of food label/ingredient list
Sample gluten free diet
Challenges of on-campus dining
Healthy gluten free choices both on and
off campus
Support groups and resources
Bread
Bagels
Cakes
Cereal
Cookies
Pasta /noodles
Pastries /pies/rolls
Beers/Lager/Ales
Safe to Consume
Starch
MaltodextrinMade from cornstarch, potato
starch, or rice starch, but not from wheat
Bouillon cubes
Brown rice syrup
Candy
Chips/potato chips
Cold cuts, hot dogs,
salami, sausage
Communion wafer
French fries
Rice
Corn
Quinoa
Amaranth
Arrowroot
Buckwheat
Montina
Flax
Jobs tears
Potatoes
Lentils
Millet
Sago
Soy
Sorghum
Tapioca
Teff
Cornstarch
Manioc
Flours made from
Nuts
Beans
Tubers
Legumes
Gluten-Free Certification
Program
Product of the Gluten Intolerant Group (GIG)
and is a non profit
Example of an independent verification of
products
Products carrying the GF logo meeting strict
gluten-free standards
GFCO is the only gluten-free certification
program in the world
http://www.gfco.org/
http://www.fns.usda.gov/fdd/facts/nutrition/foodallergenfactsheet.pdf
The Celiac Diet ,Series #8 The Gluten Free Diet: Can your patient afford it? Practical Gastroenterology April 2007; 75-84
(http://www.gluten.net/publications.php)
Eating on Campus
Working with the campus food service
Challenges galore
Examples of what others are doing
Social pressure
Lack of time / need to plan ahead
Lack of variety / deprivation
Lack of support
Cravings / temptations
Eating Out
Restaurants
Learning to interpret ingredients
Ask waitstaff or chef about ingredients
GF items now available at many restaurants
PF Changs, Outback Steakhouse, Subway, Legal
Seafood, Wendys, Chick-fil-A, Boston Market,
McDonalds, Carrabbas, Dennys, Bonefish Grill
Travel
AllergyFree Passport and GlutenFree Passport
have launched the iEatOut Gluten & Allergen
Free application
www.glutenfreepassport.com
Medline Plus
www.nlm.nih.gov/medlineplus/celiacdisease
Case Presentation
18 y.o. female incoming first year student
Health Form
Height = 4 11
Weight = 68 pounds
Expected wt. = 94 pounds
No GI symptoms
NVD, abdominal pain, appetite issues
TFTs normal
No record of bone density, EKG, postural vital signs or GI
workup
History (continued)
Meds: multivitamin
Allergies: NKDA
PMH:
10 days early for birth; birth weight 5.5 lbs
Thalassemia trait
Dietary History
Vegetarian Diet - has eggs, no fish
Breakfast toast with jam or waffles, maple syrup
butter, chocolate milk
Lunch Subway veggie delight with cheese or 2
slices of pizza
Snack Chips and famous Amos cookies
Dinner Grilled cheese sandwich or Pasta; Indian
food
Fluids Water, juice, or milk; occasional
milkshake
Physical Exam
T: 98.9
HR: 88-90 reg. BP: 120/78-118/70
Ht 411; wt 70.75 lb; BMI = 14.4
Alert, well appearing, well proportioned
Chest: CTA, full breath sounds
Cor: Regular rate and rhythm; no murmurs
Throat: normal oral pharynx
Neck: no nodes; no thyromegaly
Abdomen: soft; no HSM
Extremities: normal reflexes; no lanugo
Labs
CBC, Platelets & Differential
Thalassemia trait found all else normal
Gliadin Ab IgA
54 U/ml (negative <11, positive >17)
Bone Density
Plan
Referral to Gastroenterology
Endoscopy and biopsy Marsh 3
Referral to Nutrition
Gluten Free Diet
Referral to Counseling
Referral to Endocrine
Evaluation of osteoporosis / osteopenia
Calcium and Vitamin D supplementation
Regular Follow up
June
2009
September
2009
GOAL
Weight 68
Weight 72
BMI 13.7
BMI 14.5
BMI 14.6
BMI 19
tTG 100
tTG 58
tTG 50
tTG 0 - 8
Issues
Decision to discontinue medical visits
Started mega vitamin therapy on own
Continued intensive program of cultural dancing
several hours per day
Considerations
How do we work within context of illness which
may not be understood in another culture?
How do we deal with parents who do not believe
the diagnosis and the conflict between the
parental recommendations which are different
from the medical recommendations?
How do we separate the concerns of overexercise or possible eating issues from celiac
disease?
Without any symptoms after ingestion of wheat
what is the incentive for a patient to strictly adhere
to dietary recommendations?
Areas of Research
Celebrating
Celiac Disease Awareness Month!
Questions?
Thank you!
Contact information:
Marty Reuman Pieper mpieper@bentley.edu
Gerri Taylor gtaylor@bentley.edu
Deanna Busteed deannaconte@yahoo.com