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Celiac DiseaseChloe Bierbower

Kelly LonerganBrittany Pinkos

Sarah Steinmetz

Learning Objectives Be able to describe what Celiac Disease

is Be able to distinguish what foods should

be avoided by someone with Celiac Disease

Be able to identify possible symptoms of CD or complications

Be able to design and prepare a diet free of food products containing gluten

What is Celiac Disease? Autoimmune enteropathy triggered by

the ingestion of glutenCauses intestinal damage

Disease of both malabsorption and abnormal immune reaction to the protein gluten

Main groups of proteinsGliadins, glutenins and other alcohol-soluble

proteins found in grains� Also known as celiac sprue, nontropical

sprue and gluten- sensitivity enteropathy

What is Gluten? Composite formed from several different

proteins Found most commonly in wheat and

other related grains Used in many processed foods as a

thickener, binder, flavor enhancer and protein supplement

The Autoimmune Response

CD is the result of inappropriate T cell-mediationGlutenin and gliadin (GLU) derived peptides

act as antigensActivates lamina propria to infiltrate CD4+ T

lymphocytes from intestinal mucosa of SILeads to release of proinflammatory

cytokines (in particular y-interferon) which cause profound tissue remodeling

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Specific CD4+ T-cell responses to GLU peptides are due to genes HLA-DQ2 and HLA-DQ8

Possible to have 2 HLA-DQ2 genes, 2 HLA-DQ8 genes or one of each

2 HLA-DQ2 genes results in the highest susceptibility for CD

Presence of these genes does not mean a patient will develop CD

The Autoimmune Response cont.

Clinical Research Study Results showed that both adult and

young patients with CD can respond to diverse repertoire of GLU peptidesRegardless of which genes expressed

Inconclusive if a specific GLU protein triggers a specific immunological response

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Consequences of the autoimmune response Immune reaction attacks and destroys

small intestinal villi Small intestinal villi aids in the

absorption of nutrients Without healthy villi the SI cannot

extract and absorb nutrients from food Regardless of the quantity of food consumed

Causes? Unclear as of now It is genetic May be triggered by:

Surgery, pregnancy, childbirth, viral infection or severe emotional stress

Some gene mutations increase risk More common in people with:

Type 1 diabetes, autoimmune thyroid disease, down syndrome, and microscopic colitis

What are the symptoms of CD? Symptoms subdivided in typical or

atypical forms Symptoms vary with:

The age of the patientDuration and extent

of diseasePresence of extraintestinal

pathology Can be completely

asymptomatic

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Symptoms of CD Typical form (Typically in infants 6-18

months of age)Chronic diarrheaFailure to thriveAbdominal distentionAnorexiaMuscle waisting

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Symptoms of CD cont. Atypical form (more common in older

children and adults)Dermatitis herpetiformis Iron-deficiency anemiaShort statureDentil enamel hypoplasiaArthritis and arthralgiaChronic hepatitis and hypertransaminaemiaOsteoporosisNeurologic problemsOther GI problems

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Symptoms in Adults

Fatigue Bone or joint pain Arthritis Bone

loss/osteoporosis Depression or

anxiety Tingling/numbness

in hands and feet

Missed menstrual periods

Infertility Recurrent miscarriages Canker sores Dermatitis herpetiformis

(itchy skin rash) Seizures

Experience different symptoms:

Why are symptoms varied? Currently being studied Could depend on length of time the

person was breastfed Age the person starting consuming

gluten Amount of gluten containing foods a

person eats Condition of the persons small intestine

Medical Conditions Associated with CD Type 1 diabetes Autoimmune atrophic gastritis Autoimmune emocytopenic diseases Autoimmune thyroid disease Autoimmune liver disease Rheumatoid arthritis Addison’s disease Sjogren’s syndrome 2-5% of patients with CD develop refractory

CD, a serious complication associated with 50% risk of lymphoma development

Epidemiology of CD

Originally thought to be a rare childhood disease

Diagnosed at any age CD may develop later in life

Over 2 million Americans have CD Affects ~1 in every 133 Americans

Similar European statistic Affects ~1 in every 22 Americans with

genetic predisposition Global prevalence of CD is increasing

How is Celiac disease diagnosed? Difficult to diagnose Often mistaken for other diseases

IBS, diverticulitis, intestinal infections Histological and serological testing are

essential Look for abnormalities in SIPresence of certain IgA autoantibodies

Positive diagnosis made when:Typical SI histopathological abnormalities

Hyperplastic villous atrophyClinical remission on a strict gluten-free diet

with relief of symptoms within weeks

How is it treated?

Only known treatment is a Gluten-Free DietComplications

Food presumed to be “gluten-free” but is contaminated

Expensive Limited options Some medications and vitamins contain gluten

Supportive nutritional care with emphasis on iron and calcium

The Gluten-Free Diet

Avoid eating foods that contain:Wheat, barley, rye, and certain soy products

Foods that contain these ingredients:Cereals, pasta, and many processed foods

Important to talk to chefs, waiters and pharmacists

Foods to Avoid

Bulgar (several different wheat species)

Durum (species of wheat) Farina (cereal food, cream of wheat) Graham flour (whole wheat flour) Semolina (purified wheat from durum

wheat) Spelt (ancient wheat species) Triticale (wheat-rye hybrid) Foods that contain these unless specified

“gluten-free”

Most Common physical Complications

Malnutrition Iron deficiency anemia Loss of calcium and bone density Lactose intolerance

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Psychological and Social Effects of CD

Study conducted in the UK 130 adults with CD described living with

CD Common responses:

Living with widespread ignorance Social invisibilityCreating a celiac communityA changed identityGrief and accepting the trade-off

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How is this relevant to the health industry?

As dietitians, we will come across people with CD who require treatment

We will also come across people with symptoms that suggest a diagnosis of CD is needed

The prevalence of this disease is increasing internationally so it’s important to be aware and knowledgeable

References

(2011). Celiac Disease-Topic Overview. WebMD. Retrieved May 1, 2013, from http://www.webmd.com/digestive-disorders/

celiac-disease/celiac-disease-topic-overview. (2012). Celiac Disease. National Digestive Diseases Information Clearinghouse. Retrieved May 1, 2013, from http://digestive.niddk.nih.gov/

diseases/pubs/celiac/.Gianfrani, C., Auricchio, S., Troncone, R. (2005).

Adaptive and innate immune responses in celiac disease. Immunology Letters, 99(2), 141-145.

References

Rose, C., Howard, R. (2013). Living with celiac disease: A grounded theory study.

Journal of Human Nutrition and Dietetics.Vader, W., Kooy, Y., Van Veelen, P., De Ru, A.,

Harris, D., Benckhuijsen, W., Pena, S., Mearin, L., Drijfhout, J. W., Koning, F. (2002). The Gluten Response in Children With Celiac Disease is Directed Toward Multiple Gliain and Glutenin Peptides. Gastroenterology, 122, 1729-1737.

Questions?