2. Overview
• What is it?
• Pathophysiology
• Epidemiology
• Etiology
• Symptoms
• Clinical Manifestations
• Medical Diagnosis
• Treatment
• Nutrition Care Process
3. What is Gluten Sensitive
Enteropathy?
• Gluten Sensitive Enteropathy is a T-cell mediated
autoimmune disease of malabsorption and abnormal
reaction to gluten
• Those with this disease cannot tolerate gluten
• It is induced by ingestion of the gluten, but mainly the
peptide strand gliadin in gluten
• Gliadin is found in wheat, barley, and rye
4. What is Gluten Sensitive
Enteropathy?
• When gluten is ingested, the immune system responds by
damaging the lining of the GI tract
• This response affects the body’s ability to absorb
nutrients normally
• Disease originates from genetic, environmental, and
autoimmune triggers by the body’s abnormal response to
gluten
7. Pathophysiology
• Gliadin
• Toxic effects to intestinal barrier
• Severely damages intestinal lining
• Difficult to digest
• Longer gliadin is left undigested, the greater amount of damage it
can cause
• Undigested gliadin stimulates macrophages to release IL-8
• IL-8 activates innate immune system which triggers gut
inflammation
• Antigens then attacked
• Inflammatory response is triggered
8. Pathophysiology
• Enterocytes and Tight Junctions
• Enterocytes are intestinal absorptive cells
• Tight junctions controlled by many signals
• Zonulin
• Protein that controls opening and closing of tight junctions
• Responsible for preventing paracellular absorptions of antigens
9. Pathophysiology
• Gliadin-Zonulin interaction
• Gliadin causes zonulin levels to increase in people with this
disease
• As zonulin increases, tight junctions function abnormally by
opening wider
• This loosens the protective barrier of the gut wall
• Wider gut opening allows larger particles into enterocytes that
shouldn’t be there
10. Pathophysiology
• Gliadin accumulates under gut wall
• Enterocytes release IL-5 which triggers more inflammation
inside gut wall by releasing intraepithelial lymphocytes (IEL’s)
• IEL’s damage enterocytes
11. Pathophysiology
• Leaky Gut Syndrome
• Can be contracted depending on severity of enterocyte damage
• As gliadin accumulates behind gut wall, it crosslinks with the
enzyme, tissue transglutaminase (tTG)
• tTG is released to repair damaged enterocyte cells
• tTG-gliadin crosslinkage mistakenly attacks enterocyte cells
that produce tTG
• Triggers autoimmune response (body attacks itself)
• Microvilli eventually destroyed
12. Pathophysiology
• Microvilli
• Height decreases
• Villi are flattened
• Reduced absorptive area
• Loss of digestive enzymes
• Individuals are at a higher risk for nutrient deficiencies and
malnutrition
• Without healthy villi, a person becomes malnourished no
matter how much food they eat
• Can lead to other autoimmune diseases, anemia, osteoporosis,
and possibly cancer.
13. Epidemiology
• Affects 1 out of 250 people
• Likelihood of contracting the disease increases when a
first-degree relative has it
• Associated with other autoimmune syndromes
• More commonly seen in these populations by a 5-10%
increase
• Type 1 Diabetes Mellitus
• IgA deficiency
• Hyper-and hypothyroidism
• Turner and Down Syndromes
14. Epidemiology
• Women comprise 75% of newly diagnosed adult cases
• Genetics beginning to be identified as contributing factors
in the cause of CD
• Several genes found to be present in 95% of all patients
• Sometimes triggered after surgery, pregnancy, childbirth,
viral infections, or severe emotional distress
15. Etiology
• Damage to intestinal mucosa is accompanied by an
inflammatory response in which WBC’s enter the mucosa
• Disease has an autoimmune nature
• Essentially the body attacks itself every time gluten is ingested
16. Etiology
• Environmental factors that appear to increase risk:
• Introducing gluten at a younger age
• Shorter length of breastfeeding time
• Amount of gluten containing foods
• Viral infections during infancy
• Symptoms vary based on age and degree of damage to the
small intestine
• Many have this disease for a decade before being diagnosed
• The longer a person goes undiagnosed and untreated, the
greater the chance of developing long-term complications
• Left untreated it can cause anemia, osteoporosis, or cancer
17. Symptoms
• In infants
• Impaired growth, diarrhea, abdominal distention
• In older children
• Short stature, pubertal delays, rickets, dental enamel defects,
behavioral disturbances and poor school performance
18. Symptoms
• In adults
• GI system: diarrhea, abdominal pain, cramping, bloating, gas
production
• Nervous System: seizures, tingling or numbness in hands/feet
• Skeletal system: bone pain, arthritis
• Psychiatric: depression and anxiety
• Miscellaneous: infertility, alopecia, hypoglycemia and weight loss
19. Clinical Manifestations
• Dermatitis Herpetiformis
• >10% of adults with CD
• Extremely itchy, chronic rash made of bumps and blisters
• On elbows, knees, back and buttocks
• Histological change in small intestine with mild or no GI
symptoms
• Treated with an antibiotic or strict gluten-free diet
• More likely to develop thyroid disease and certain cancers of the
intestines
21. Clinical Manifestations
• Iron-Deficiency Anemia
• 50% of patients with CD are anemic
• Iron is absorbed in proximal small intestine where celiac
manifestations are most prominent
• Causes iron malabsorption
• Most common manifestation of CD
• Less commonly,
• Vitamin B12 deficiency, folate deficiency
22. Abnormal Lab Findings
• Decreased albumin
• malnutrition
• Elevated calcium, decreased phosphate
• Vitamin D deficiency, secondary hyperparathyroidism
• Low HDL and LDL
• Decreased fat absorption
• Coagulopathy
• Decreased vitamin K absorption
23. Medical Diagnosis
• Positive serologic test
• IgA anti-endomysial antibodies
• Measured using direct immunofluorescence
• IgA transglutaminase antibodies
• Measured using ELISA (assay)
• IgG and IgA anti-gliadin antibodies
• Measured using ELISA (assay)
• Presence of antibodies correlates to intestinal damage
24. Medical Diagnosis
• Distal Duodenal Biopsy
• Gold standard
• Esophagogastroduodenoscopy (EGD)
• Pathologist evaluates tissue sample for
• loss of villi
• increased number of lymphocytes
25.
26. 4 Main Categories
• Classical Celiac Disease
• Symptoms of GI malabsorption
• Diagnosis by serological testing and intestinal biopsy
• Symptom improvement with gluten free diet
• Celiac Disease with Atypical Symptoms
• Few to no GI symptoms
• Diagnosis by serological testing and intestinal biopsy
• Symptom improvement with gluten free diet
27. 4 Main Categories
• Silent Celiac Disease
• Asymptomatic individuals
• positive serological and biopsy tests
• Detected via screening of high-risk individuals
• Latent Celiac Disease
• Positive serological test
• no villous atrophy on biopsy
• Asymptomatic at first but may develop symptoms later
28. Treatment
• Exclusion of dietary gluten results in
• healing of mucosa
• resolution of malabsorptive state
• reversal of most effects of the disease
• People with CD can still eat a well-balanced diet with a
variety of foods
• plain meats, fish, rice, fruits, and vegetables.
30. Treatment
• Doctor will prescribe a gluten free diet and a consult with a
RD
• No wheat, barley, rye and sometimes oats
• Foods to avoid:
• Breaded foods
• breads
• bagels
• cakes
• donuts
• most cereals
• cold cuts
• hot dogs
• crackers,
• potato chips
• gravy
• pizza
• most soups
• beer
• some candies
• communion
• croutons
• marinades
• Sauces
• some salad
dressings
31. Treatment
• What to eat
• Alternative grains rice, buckwheat, tapioca, potato or corn
flours
• Potatoes, rice flax, millet
• Legumes, nuts, seeds and cassava
• Oats are subject of controversy
• By themselves are nontoxic in limited quantities
• Commercial oat products are often contaminated with wheat
• Consult RD and doctor if seeking advice
32. Nutrition Care Process
I. Assessment
II. Diagnosis
III. Intervention
IV. Monitoring and Evaluation
33. Nutrition Care Process:
Assessment
• Assess food and nutrient intake
• Diet hx
• Macronutrient and micronutrient intake
• Calcium, Iron, B vitamins, vitamin D
• Knowledge/beliefs/attitudes
• Behavior
• Factors affecting access to food
• Food intake assessment is necessary to determine nutrition
dx and plan intervention.
34. Nutrition Care Process:
Assessment
• Assess biochemical data
• GI profile
• Intestinal biopsy
• Celiac antibodies
• Nutritional anemias (iron deficiency anemia common)
• Folate
• Ferritin
• B12
• Vitamin profile
• Thiamin
• Vitamin B6
• 25-hydroxy vitamin D
• Mineral profile
• Copper
• Zinc
• Lipid profile
• Electrolyte and renal profile
• Biochemical assessment is necessary because CD results in damage
to the intestinal villi, leading to malabsorption.
35. Nutrition Care Process:
Assessment
• Bone density screening
• Recommended within the first year of diagnosis
• Studies and trials show reduced bone mineral content and
density in adults with untreated CD
• Factors affecting quality of life
• Medical hx
• Any possible GI, immune, neurological, or psychological issues
• Social hx
• Socioeconomic factors, religion, social and medical support, stress
level
• Individuals with CD may not have the same quality of life as
people around them due to the inconveniences that go with
following a gluten-free diet.
36. Nutrition Care Process:
Assessment
• GI symptoms
• Frequency and volume of BM
• Abdominal pain and bloating
• Nausea and vomiting
• Reduced gut motility
• Delayed gastric emptying
• People with CD, both treated and untreated, experience
more GI symptoms.
37. Nutrition Care Process:
Assessment
• Other disease states
• Thyroid conditions
• Autoimmune disorders
• Endocrine disorders
• Diabetes
• RD needs to consider other disease states when
implementing interventions
38. Nutrition Care Process: Diagnosis
• RD cannot diagnose CD
• IDNT Nutrition Diagnostic Terminology
• Intake
• Increased nutrient needs (specify) NI-5.1
• Iron
• B12
• Vitamin D
• Calcium
• Clinical
• Functional
• Altered GI function NC-1.4
• Biochemical
• Impaired nutrient utilization NC-2.1
• Behavioral
• Knowledge and Beliefs
• Food and nutrition knowledge related deficit NB-1.1
• Not ready for diet/lifestyle change NB-1.3
• Limited adherence to nutrient-related recommendations NB-1.6
• Undesirable food choices NB-1.7
39. Nutrition Care Process:
Intervention
• Gluten-free diet
• Long-term compliance required
• Will improve villous atrophy, GI symptoms, bone density, iron
deficiency anemia, pregnancy outcomes, and quality of life
• Lactose-free diet
• Secondary lactase deficiency common with CD
• Damage to villi and impaired enzyme secretion
• As villi heal, lactose can be added back to diet
• Usually not required long-term
40. Nutrition Care Process:
Intervention
• Consumption of whole/enriched gluten-free grains and
products
• Still need a source of CHO and fiber, but must be gluten-free
• Rice, wild rice, buckwheat, quinoa, amaranth, millet, oats*
• Oats Controversy
• Oats and oat products are sometimes contaminated with wheat,
barley, or rye
• Nutrition practice guidelines say up to 50mg of oats/day is safe
and generally tolerated.
• Individuals can tolerate oats as long as oats are from a pure,
uncontaminated source
41. Nutrition Care Process:
Intervention
• Inclusion of a multivitamin and mineral supplement
• Gluten-free diet may result in low consumption of iron, folate,
niacin, B12, calcium, phosphorous, and zinc
• If diet shoes inadequacy, multivitamin supplement is
recommended
• Gluten-free
• Age and gender appropriate
• Calcium and vitamin D
• Gluten-free diet may improve but not normalize bone mineral
density
• Individuals may have low levels of 25-hydroxy vitamin D
• Increase consumption of calcium and vitamin D
• Through food or supplements
42. Nutrition Care Process:
Intervention
• Iron supplementation
• For iron deficiency anemia
• Supplementation to achieve normal levels
• Other measures aimed to increase iron absorption can also be
recommended
• Intake of heme-iron
• Intake of iron with ascorbic acid
• Avoiding tannin containing items
43. Nutrition Care Process:
Intervention
• Education on label reading
• How to review ingredients on food labels and supplements in order to
avoid sources of gluten
• Wheat, rye, barley, malt, oats*
• Education on food cross-contamination
• Patient needs to be aware of possible cross contamination of foods with
gluten in manufacturing plants, restaurant, and at home
• Coordination of care
• RD may refer patient to another clinical professional based on
coexisting conditions
• Gastroenterologists
• Endocrinologists
• Allergists
• Dermatologists
• Hepatologists
• Pharmacists
• Social workers
44. Nutrition Care Process:
Intervention
• Example:
• Provide nutrition education on label reading and how to
identify gluten containing ingredients.
45. Nutrition Care Process:
Intervention
Foods Allowed Foods to Question Foods to Avoid
Milk and Dairy
Flavored yogurt, frozen
Milk, cream, most ice
yogurt, cheese sauces,
cream, plain yogurt,
cheese spreads
cheese
Malted milk, ice cream
made with ingredients not
allowed
Breads
Breads made with
amaranth, arrowroot,
buckwheat, corn bran, corn
flour, cornmeal, cornstarch,
legume flour, flax, potato
flour, pure uncontaminated
oat flour
Items made with
buckwheat flour
Items made with wheat
bran, wheat flour, wheat
germ, commercial oat
products
Pastas
Pastas made from beans,
corn, lentils, peas, potato,
quinoa, rice, soy, or wild
rice
Buckwheat pasta Pastas made from wheat
and other ingredients not
allowed
46. Nutrition Care Process:
Intervention
Foods Allowed Foods to Question Foods to Avoid
Meat, Fish, Poultry
Plain, fresh or frozen
Deli meats, hot dogs,
sausages, meatloaf, ham,
jerky, meat substitues
Canned meats in broth
containing hydrolyzed
wheat protein
Meat breaded with flour
Eggs
Fresh, liquid, or dried
Flavored egg products
Fruits
Fresh, frozen, and canned
fruits and juices
Dates, fruits with sauces
Vegetables
Fresh, frozen, and canned
vegetables and juices
Vegetables with sauces,
vegetables cooked in oil
also used for gluten
containing products
Scalloped potatoes,
battered and fried
vegetables
47. Nutrition Care Process:
Monitoring and Evaluation
• Dietary compliance
• RD needs to monitor
• Gluten-free diet
• Antibody levels
• Any exposure to cross contamination
• Any hidden sources of gluten in foods, medications, and supplements
• Monitoring the above is necessary to evaluate dietary compliance
• Factors affecting quality of life
• Changes in medical status
• GI, immune, neurological, psychological symptoms
• Changes in social status
• Socioeconomic factors, religion, social support, medical support, stress levels
• GI symptoms
• Bloating, gas, constipation, diarrhea
• Lactose intolerance
• Infections
• Related cancers
• Gluten-free diet reduces but may not always eliminate symptoms
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Editor's Notes
Extra intestinal manifestations predominate (i.e. thyroid disorders or psoriasis)
