1. The Role of Nutrition in
Gluten Sensitive Patients
Carly Lewis, UNH Dietetic Intern
April, 2015

2. What is Gluten?
 A protein found in wheat, rye and barley
 Helps foods maintain their shape, acting as a glue that holds food together
 Can be found in many types of foods, even ones that would not be
expected
http://www.precisionnutrition.com/wordpress/wp-content/uploads/2009/10/gliadin-glutenin-gluten.gif

3. Common Sources
 Wheat
 Varieties and derivatives of wheat such as:
 wheatberries
 durum
 emmer
 semolina
 spelt
 farina
 farro
 graham
 KAMUT® khorasan wheat
 einkorn wheat
 Rye
 Barley
 Triticale
 Malt in various forms including: malted barley flour, malted milk or
milkshakes, malt extract, malt syrup, malt flavoring, malt vinegar
 Brewer’s Yeast
 Wheat Starch that has not been processed to remove the presence of
gluten to below 20ppm and adhere to the FDA Labeling Law*
http://www.livingherbalfarmacy.com/wp-content/uploads/2014/02/gluten-warning.jpg

4. Labeling Rules
 Food and Drug Administration
 Must meet all requirements:
 Contain less than 20 parts per million of gluten
 Manufactured in a gluten-free facility
 If a food does not have a "gluten-free" claim on the package, check
directly with product manufacturers for more information
 Ingredients such as modified food starch, malt or soy sauce also
contain gluten

5. What Causes Intolerance?
 Possibly, the introduction of gluten-containing grains
 Grains introduced 10,000 years ago with new agricultural practices
 Represented a "mistake of evolution"
 Created conditions for human diseases related to gluten exposure
 Best known complications are mediated by the adaptive immune system
 Wheat allergy
 Celiac disease

6. Celiac Disease
 An autoimmune condition that affects one in 133 people
 Releases antibodies that attack the intestinal tract
 Difficult to absorb nutrients
 Causes unpleasant symptoms
 Untreated, celiac can also lead to complications

7. Managing Celiac Disease
 Not just eliminating gluten from your diet
 Make sure you get all the vitamins and nutrients you need
 Watch weight gain

8. Non-Celiac Gluten Sensitivity
 Non-celiac gluten sensitivity (or NCGS) is believed to be more widespread
that celiac
 Similarity: involves an immune reaction to gluten
 Difference: doesn’t produce damaging antibodies
 Currently, the only treatment for celiac disease or NCGS is a gluten free diet
 There are no established laboratory markers for non-celiac gluten sensitivity

9. NCGS
 Gluten reactions in which neither allergic nor autoimmune mechanisms are
involved
 Overall clinical picture is less severe
 Not accompanied by the concurrence of tTG autoantibodies or autoimmune disease
 Ruled out celiac disease, wheat allergy and other clinically overlapping
diseases
 Type 1 diabetes
 Inflammatory bowel diseases
 Helicobacter pylori infection
 Symptoms triggered by gluten exposure and alleviated by gluten withdrawal

10. How is it Diagnosed?
 Celiac disease
1. A medical review of symptoms
2. A blood test to look for high levels of certain auto-antibodies
3. A biopsy of tissue from the small intestine
 NSGS
1. Rule out Celiac Disease and other related disorders
2. Elimination diet and then a “challenge”

11. What are the Symptoms?
 GERD and irritable bowel syndrome (IBS) like symptoms
 Abdominal pain
 Bloating
 Diarrhea, constipation and alternating bowel symptoms
 Extra-intestinal manifestations
 “Foggy mind”
 Headache
 Fatigue
 Joint and muscle pain
 Leg/arm numbness
 Eczema/rash
 Depression/anxiety
 Anemia
 Occur soon after gluten ingestion, rapidly improve after gluten
withdrawal and relapse in a few hours or days after gluten
challenge

12. Who has to be Gluten Free?
 Currently at least 0.5% of the US population follow a GFD without having a
confirmed diagnosis of celiac disease
 Even in the absence of celiac disease, gluten is thought to be associated
with bloating, diarrhea, abdominal pain, fatigue and nausea
 Leading to the definition of a new entity (NCGS)

13. What the Research Suggests

14. FODMAPs
 In addition to gluten, other triggers involved in NCGS pathogenesis have
been recently identified
 Wheat proteins (i.e. amylase- and trypsin- inhibitors) and
 Fermentable oligo-, di-, mono-saccharides and polyols (FODMAPs)
 Note: a GFD leads to a significant reduction of dietary FODMAPs
 Which leads to an improvement of the GI symptoms of the patients

15. FODMAPs
 Low FODMAP diet followed
 In all participants, GI symptoms consistently and significantly improved
during reduced FODMAP intake
 Symptoms significantly worsened to a similar degree when their diets
included gluten or whey protein

16. FODMAP Review
http://www.mintecibs.com.au/images/treating_IBS_figure02.gif

17. Gut Permeability
 The patients who fulfilled the GS diagnostic criteria (see Methods section)
experienced symptoms overlapping those presented by CD patients
 Their symptoms resolved within a few days after the implementation of the
gluten-free diet
 They remained symptom-free for the entire follow-up period (up to 4 years)
 Those with CD took longer for symptoms to resolve
 Symptoms were still present at times even when following GFD

18. Gluten in the Gut
https://www.stuffed-pepper.com/wp-content/uploads/2015/02/8N76zh30U-tCVoF8H-vffQ.jpg

19. Immune Responses
 Disappearance of anti-gliadin antibodies of IgG after 6 months of GFD
 93.2% of non-celiac gluten sensitivity patients
 In contrast, 40% of celiac patients displayed the persistence of these antibodies
after gluten withdrawal.
 In NSGS patients anti-gliadin antibodies IgG persistence after gluten
withdrawal was significantly correlated with the low compliance to gluten-
free diet and a mild clinical response.

20. Immune Response
 Both adaptive and innate immunity play a major role in Celiac Disease
 Only innate immunity has been thought to be activated by gluten proteins
in NCGS
 Recent research suggests adaptive immunity may play a role in NCGS
 CD is a well-recognized autoimmune disease
 Whereas NCGS is likely a gluten hypersensitivity without an established
involvement of autoimmunity

21. Gluten Free Diets and Irritable Bowel Disease
 Participants with IBD selected
 Diagnosis of CD reported by 10 (0.6%)
 Diagnosis of NCGS reported by 81 (4.9%)
 314 participants (19.1%) reported having previously tried a GFD
 135 participants (8.2%) reported current use of GFD
 Adherence was in 41.5%
 Average in 34.1%
 Fair/poor in 24.4%.

22. GFD with IBD Continued
 Excellent adherence to a GFD associated with reduced fatigue
 Compared to fair/poor adherence (p<0.03)
 Of all clinical symptoms, only fatigue improved significantly with good
adherence
 Fatigue in the absence of iron deficiency anemia is a leading symptom in
many patients with IBD
 Iron absorption is inhibited in those with NSGS and CD

23. Clinical
Recommendations

24. Clinical Recommendations
 Celiac serologies (tTG or DGP) are an important first step in diagnosis
 Those with positive serology are highly likely to have CD
 Those with borderline serology can undergo HLA typing to determine the
need for biopsy
 Those with negative serology who also lack clinical evidence of
malabsorption and CD risk factors are highly likely to have NCGS and may
not require biopsy

25. Differentiation of CD and NCGS
*Nutrient deficiency is defined as vitamin D, iron, vitamin B12, or Zn deficiency

26. Clinical Recommendations
 Patients/Clients with both Celiac Disease and Non-Celiac Gluten Sensitivity
should follow a gluten free diet
 Eliminates complications of other conditions
 Maximizes ability of the gut to absorb and digest
 Reduces fatigue
 Each individual has a different threshold
 More research needs to be conducted on benefits and downfalls of
incorporating gluten into the diet of people with NCGS

27. Case Study

28. Case Study
 56 year old male
 Worked in IT department
 Now off on disability
 Declining activity level over 3-6 months
 Spends most days in bed
 Recent trouble walking at home, too shaky to use his cane
 Marital status: boyfriend for 36 years

29. Symptoms
 Increased confusion, trouble ambulation, chills, fever
 Progressive coordination issues
 Declining executive function over 48hrs

30. Presenting Diagnosis
 Altered mental status, failure to thrive, severe protein malnutrition
 Relevant medical history
 Chronic hepatitis C
 Oral cancer – palliative chemo and radiation
 Hemochromatosis
 Celiac disease
 Smokes 1-1.5 ppd, excessively drinks (sober for 3 weeks)

31. Clinical Findings
 Confusion
 Fever, possible aspiration pneumonia
 Possible alcohol withdrawal
 Sepsis
 Severe protein malnutrition
 Cachectic limbs
 105lbs – BMI 15.6
 Poor dentition

32. Lab Results
 ABG for CO2 narcosis
 MELD score of 11
 3-month mortality rate of 6%
 MRI for possible brain abnormality
 CBC
 ? Sign of aspiration pneumonia
 Malnutrition
 ? Liver dysfunction

33. Recommended Interventions
 Encourage increased protein-energy consumption
 Some skin breakdown on sacrum
 Address vitamin and mineral deficiencies
 Speech therapy evaluation for poor dentition and rotting teeth
 Promote gradual weight gain

34. Possible Gluten-Related Issues
 Anemia
 Protein-Energy Malnutrition
 Neurological changes

35. Hospital Course
 Cognition improved but then declined again
 Admitted to the ICU
 PEG placed at brother’s wishes
 Patient refed after only eating 10-15% of meals during stay
 Dispute over plan of care between family and significant other
 Ultimately passed away

36. Questions?
http://www.glutenfreeclub.com/wp-content/uploads/gluten_free_club_cartoon_gluten-ectomy.jpg

37. References:
 Ansel, Karen. “Does My Child Need a Gluten Free Diet?” Academy of Nutrition and
Dietetics. 21 January 2014. Web.
 Biesiekierski, Jessica R., et al. “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: 320-328.
 Caio, Giacomo, Umberto Volta, Francesco Tovoli, Roberto DeGiorgio. “Effect of gluten
free diet on immune response to gliadin in patients with non-celiac gluten sensitivity.” BMC
Med (2014) 14: 26.
 Herfarth, Hans H., Christopher F. Martin, Robert S. Sandler, Michael D. Kappelman, Millie D.
Long. Prevalence of a gluten free diet and improvement of clinical symptoms in patients
with inflammatory bowel diseases.” Inflammatory Bowel Diseases (2014) 7:1194-1197.
 Kabbani, Toufic A., et al. “A clinical predictive model for differentiation of celiac disease
and non-celiac gluten sensitivity. Gastro Journal.
 Lauret, Eugenia, Luis Rodrigo. Celiac disease and autoimmune-associated conditions.”
BioMed Research International (2013).
 Marcason, Wendy. “Understanding Celiac Disease”. Academy of Nutrition and Dietetics.
23 October 2014. Web.
 Sapone, Anna, et al. “Divergence of gut permeability and mucosal immune gene
expression in two gluten-associated conditions: Celiac disease and gluten sensitivity.” BMC
Med (2011) 9: 23.
 “Sources of Gluten.” Celiac Disease Foundation. 2015. Web. <http://celiac.org/live-gluten-
free/glutenfreediet/sources-of-gluten/>