Weighing in on the Gluten-Free Diet

Transcription

1 Weighing in on the Gluten-Free Diet Melinda Dennis, MS, RDN Nutrition Coordinator, Celiac Center Beth Israel Deaconess Medical Center Boston MA, USA

2 Disclosures Co-author of Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free. AGA Press,

3 Today s Objectives Review how celiac disease (CD) and the quality of the gluten-free diet (GFD) impact nutritional status Review general healthy dietary advice for the GFD Specify recommended nutritional management of the patient with CD

4 Initiation and lifelong maintenance of the GFD remains the cornerstone of therapy in CD.

5 CD s Impact on Health Severity of nutritional deficiency is affected by at least 5 factors 1 Length of time with active, undiagnosed CD 1,2 Extent and location of damage 1,2 Degree of malabsorption of nutrients 1,2 Medications that block absorption or increase demand of nutrients Quality of GFD 1. Saturni. Nutrients 2010; 2. Garcia-Manzanares. Nutr Clin Prac 2011

6 Newly Diagnosed: Vitamin & Mineral Deficiencies and Weight Concerns 80 newly diagnosed CD adult patients (42.8 +/ years) 24 healthy Dutch controls Vitamin A: 7.5% Vitamin B6: 14.5% Folic acid: 20% Vitamin B12: 19% Zinc: 67% 46% decreased iron stores 32% anemia 17% malnourished 22% women underweight 29% men & women overweight Vitamin deficiencies were barely seen in healthy controls w/ exception of Vitamin B12. Wierdsma. Nutrients Oct 2013

7 Vitamin & Mineral Deficiencies in CD and GFD Low in Blood Work AND Diet Iron (Ferritin in blood work) Vitamin D Additionally Low in Diet Phosphorus Fiber B vitamins Calcium, Magnesium Zinc Saturni. Nutrients 2010; Theethira Expert Rev Gastroenterol Hepatol 2014; Barton. Gastroenterol Clin N Am 2007; Dahele Am J Gastroenterol 2001; Halfdanarson Blood 2007; Tikkakoski Scand J Gastroenterol 2007; Chakravarthi Indian J Gastroenterol 2012; Lerner. Clin Rev Allergy Immunol 2012; See. Nutr Clin Prac 2006; ADA (now Academy of Nutrition and Dietetics[AND]) Evidence Analysis Library: Celiac Disease 2011; Thompson. J Hum Dietet 2005; Hallert. Aliment Pharmacol Ther 2002; Thompson. JADA (now AND) Garcia Manzanares. Nutr Clin Prac 2011

8 Imbalance of the GFD Following a diet based on gluten-free products could suppose a nutritional imbalance for celiac patients as well as non celiac patients who follow a diet that includes many gluten-free related foodstuffs. (1) Foods for special medical purposes should contain nutrients at the levels found in the foods they are intended to replace. (2) 1. Miranda. Plant Foods Hum Nutr Pelligrini J Sci Food Agric 2015

9 Nutritional Quality of the GFD Study Team Lee, 2009 US Kinsey, 2007 UK Thompson, 2005 US Hallert, 2002 Sweden Hopman, 2006 Netherlands Conclusions 38% meals/snacks had no grain; (rice 44%) Adding whole GF grains improved protein, iron, calcium and fiber content Patients w/ CD consumed less calcium, vitamin D, calories, fat, and fiber than recommended, and more protein Women meeting needs: 46% fiber; 21% grains; 31% calcium; 44% iron Men: 88% fiber; 63% grains; 63% calcium; 100% iron Daily intakes of folate and vitamin B-12 were lower in patients with CD; some nutritional deficiencies have been seen after treatment with the GFD for ~10 years Lower fiber and iron intake and higher saturated fat intake than recommended but comparable to general population

10 Negative Factors Affecting Quality of GF Products STARCHES FAT, TRANS FAT CALORIES SUGAR KEY NUTRIENTS FIBER ENRICHED/FORTIFIED PRODUCTS COST Miranda. Plant Foods Hum Nutr 2014; Kupper Gastroenterol 2005; Thompson. J Hum Nutr Dietet 2005; Lee. J Hum Nutr Diet 2009;Thompson J Am Diet Assoc (now AND) 2000; Shepherd J Hum Nutr Diet 2012; Pelligrini J Sci Food Agric 2015

11 Comparison of GF and Gluten-Containing Flours White Rice Flour Tapioca Starch Cornstarch Potato Starch Enriched White Flour Whole Wheat Flour Protein (g) Fiber (g) Carbohydrate (g) Iron (mg) Calcium (mg) Zinc (mg) 1.3 N/A 0.1 N/A Magnesium 55 N/A 4 N/A (mg) Thiamin (mg) 0.22 N/A Riboflavin (mg) 0.03 N/A Folate (mcg) 6 N/A 0 N/A Courtesy of: Gluten-Free Diet: The Definitive Resource Guide by Shelley Case, RD, 2015 (in press).

12 Weight of Patients with CD at Diagnosis About one-half of the adult population in western countries is overweight or obese. Mean body mass index is increasing. Similar trend in CD 4-5% underweight 40% overweight at diagnosis Obesity is increasingly seen as part of the initial presentation of CD. Ukkola. Eur J Int Med 2012; Tucker. J Gastrointesin Live Dis 2012; Dickey. Am J Gastroenterol 2006; Sonti et al Gastro and Hepatology 2012

13 Effect of GFD on BMI on Patients with Newly Diagnosed CD Country Subjects Results Ireland Dickey, 2006 United States Cheng, 2010 United States Kabbani, 2012 Finland Ukkola, patients; BMI at diagnosis and 2 years later 369 patients; BMI at diagnosis and after 2.8 years 679 patients; BMI at diagnosis and after almost 3 years 698 patients; BMI at diagnosis and 1 year later 81% gained weight after 2 years (including 82% of initially overweight patients) 66% of underweight gained weight; 54% of overweight and 47% obese lost weight; GFD had beneficial effect on BMI 21% normal or high BMI at study entry rose by 2 points (15.8% moved from normal or low BMI to overweight; 22% overweight at diagnosis gained weight); majority remained in same BMI category BMI improved similarly in screen and symptom detected patients on GFD; overweight/obese lost and underweight gained

14 Weight Gain on the GFD Overall, patients with CD on a GF diet tend to gain weight. A few theories: Symptom resolution PLUS better absorption of food with SAME caloric intake = WEIGHT GAIN Used to eating large portions of food GF diet is NOT inherently healthy Whole healthcare team needs to address risk of weight gain Dietitian: diet and lifestyle (exercise) counseling Sonti Gastro Hepatol 2012; Kabbani Aliment Pharmacol 2012; See. Nutr Clin Prac 2006; Tucker Gastrointestin Live Dis 2012; Dickey Am J Gastroenterol 2006; Valletta Eur J Clin Nutr 2010

15 Key Elements in the Management of CD Consultation with a skilled dietitian Education about the disease Lifelong adherence to a gluten-free diet Identification and treatment of nutritional deficiencies Access to an advocacy group Continuous long-term follow-up by a multidisciplinary team NIH Consensus Development Conference on Celiac Disease, 2004

16 Enhancing Nutrition of the GFD Select naturally GF foods. Emphasize the quality of the GFD (especially for women) as it concerns FIBER, IRON, and CALCIUM. Consume whole or enriched LABELED gluten-free grains and products such as brown rice, wild rice, buckwheat, quinoa, amaranth, millet, sorghum, teff, etc. Choose 6-11 servings (depending on calories) of GF grain foods daily, especially whole or enriched. At least half of the grain servings each day should come from whole grain sources. 3 servings/day (oats, brown rice, quinoa) positively impacts the nutrient profile (fiber, thiamin, riboflavin, niacin, folate and iron) of the grain portion of the diet and is less costly. Select enriched/fortified GF products, (especially B vitamins - thiamin, riboflavin and niacin) during pregnancy and lactation. Penagini Nutrients 2013; Thompson JADA (now AND) 1999; Shepherd JHND 2012; Thompson JADA (now AND) 2000; Lee JHND American Diet Assoc (now AND) EAL Celiac Disease Toolkit USDA Dietary Guidelines for Americans 2010

17 Gluten-Free Whole Pseudo/Grains, Seeds & Legumes GRAINS/SEEDS Amaranth Buckwheat Brown rice Corn Flax seed Millet Oats (specially labeled gluten-free) Popcorn Quinoa Sorghum Teff Wild rice BEANS & LEGUMES Black Beans Edamame (fresh soybeans in pod) Garbanzo beans (chickpeas) Lentils Lima beans Peas Pinto beans Soybeans Kidney beans Black-eyed peas Butter beans Adapted with permission: Higgins, L. Whole Grains=Nutritional Gold. In Real Life with Celiac Disease. Dennis, M, Leffler D., eds. AGA Press, Bethesda, MD, 2010.

18 Specific Nutrient Content of Whole GF Pseudo/Grains Flours Fiber (gm) Folate (mcg) Calcium (mg) Iron (mg) Amaranth Buckwheat groats Millet Quinoa Sorghum Wheat flour, whole-grain Wheat flour, white enriched USDA National Nutrient Database,

19 Flours B Vitamins Content of Whole GF Pseudo/Grains Thiamine (B1) (mg) Riboflavin (B2) (mg) Niacin (B3) (mg) B6 (mg) Amaranth Buckwheat groats Millet Quinoa Sorghum Teff Wheat flour, whole-grain Wheat flour, white enriched USDA National Nutrient Database,

20 Gluten Contamination of Grains, Seeds, and Flours in the U.S: A Pilot Study 22 inherently gluten-free grains, seeds, and flours not labeled GF were analyzed for gluten Samples were homogenized and tested in duplicate using R5 ELISA assay 22 Samples 13 (59%) Contained <5 ppm 2 (9%) Contained mean levels (8.5-<20 ppm) 7 (32%) Contained mean levels 20 ppm Thompson T, Lee A, Grace T. JADA (now AND), Study funded in part by Schar USA.

21 Enhancing Nutrition of the GFD (cont d) Base daily energy requirements on age, gender, and physical activity. Increase NON-grain food sources of iron & B vitamins (folic acid), particularly for pregnant and nursing females, children and adolescents. Select 3 servings/day (varies by need) of lowfat or nonfat dairy, or calcium and vitamin D fortified, non-dairy foods. Limit total fat to 20-35% (variable); sat fat to <10% and trans fat limited to <1% (as little as possible) of total daily caloric intake* Take GF vitamin/mineral, iron, calcium and vitamin D supplements, as recommended. Pay special attention to GF labeling in your country or when traveling abroad. Penagini Nutrients 2013; Thompson 2005; Thompson JADA (now AND)2000; See. Nutr Clin Prac 2006.; * USDA Dietary Guidelines for Americans 2010

22 Calcium/Vitamin D for Reduced Bone Density For adults with reduced bone density or reduced serum levels of 25 OHD, the RD should advise the consumption of additional calcium and vitamin D through food or gluten-free supplements. Studies in adults with untreated celiac disease have shown that a gluten-free dietary pattern improves, but may not normalize bone density. [Strong, conditional] American Dietetic Assoc (now AND). Evidence Analysis Library Celiac Disease Toolkit, 2011

23 Multivitamin/Mineral Recommendation If usual food intake shows nutritional inadequacies that cannot be alleviated through improved eating habits, the dietitian should advise individuals with CD to consume a daily gluten-free age- and sex-specific multivitamin/mineral supplement. [Strong, conditional] American Dietetic Assoc. (now AND) Evidence Analysis Library Celiac Disease Toolkit, 2011; Kupper. Gastroenterol 2005; Thompson JHND 2005

24 Recommended CD Labs CBC (hemoglobin, hematocrit, etc.) 25 OH Vitamin D Vitamin B12 Folate (regional) Iron and Ferritin Zinc IgA-TTG and/or DGP TSH As Needed Calcium, Magnesium, PTH Folate Other B vitamins Fat soluble vitamins: A, E, K Lipids Selenium, Copper Courtesy of Celiac Center, Beth Israel Deaconess Medical Center, Boston MA 2015

25 Recommended Nutritional Management of CD in Adults Nutrient Epidemiology Testing Recs Treatment Recs Iron Deficiency in 28-50% patients at diagnosis; one of the most common extraintestinal manifestations Vitamin D Low levels in 20-66% patients at diagnosis, even in high sunshine areas Folic acid Deficiency in 18-42% patients at diagnosis; deficiency rare in No. America Serum iron and ferritin at diagnosis; repeat every 3-6 months until ferritin normal; then every 1-2 yrs or for symptoms 25 OHD level at diagnosis; every 3 mos until normal; every 1-2 yrs or for symptoms Serum folate at diagnosis in at-risk; check all women planning pregnancy Iron (325mg) 1-3 tablets based on initial ferritin until iron restored; IV iron for severe symptomatic iron deficiency anemia or intolerance of oral iron 1000IU or more/day based on 25 OHD level; 50,000IU/week if levels <20ng/mL Folic acid 1mg/day x 3 months; once diarrhea improves mcg/day Theethira. Expert Rev Gastroenterol Hepatol 2014

26 Recommended Nutritional Management of CD in Adults Nutrient Epidemiology Testing Recs Treatment Recs Vitamin B12 Deficiency 8-41% in patients at diagnosis; suspected secondary to SIBO Zinc Deficiency in 54-67% patients at diagnosis; most commonly deficient trace mineral Calcium Dietary Fiber >50% patients consume less than RDI of calcium Deficient intake of GFD causes constipation; deficiency in both genders in Europe and US MONITOR for overdosing of iron, calcium, vit D, B3, B6, and fat soluble vitamins. Serum B12 at diagnosis; then every 1-2 yrs or for symptoms Serum zinc at diagnosis; repeat every 3 mos until normal; every 1-2 yrs or for symptoms Regular dietary assessment by RD Regular dietary assessment by RD 1000mcg orally until normal; then daily multivitamin/mineral (MVM) Zinc supplement 25-40mg/day until normal; then MVM mg/day* [* Depends on individual] 25-35g/day based on age and gender; encourage alternative grains w/ high fiber and adequate water Theethira. Expert Rev Gastroenterol Hepatol 2014

27 Recommended CD Post-diagnosis Follow-up with a Registered Dietitian Visit #1 (45-90 minutes) Nutritionist (RDN) Visit #2 (45-90 minutes) 2-4 weeks later Visit #3 (30-45 minutes) 6 months after diagnosis Annually thereafter Varies widely across the country; dependent on many factors Celiac Disease Toolkit. American Dietetics Association (now AND), 2011

28 Heal and Support the Gut Eat whole, unprocessed food as much as possible. Space regular meals and snacks. EAT GLUTEN FREE. Prioritize exercise & social connections.. Drink fresh water. Take appropriate GF supplements, as directed by healthcare provider.

29 Summary The GF population needs more foods High in fiber, B vitamins, iron Nutrient rich Low in added sugar Uncontaminated by gluten Naturally low in fat & sodium Reasonably priced And free of major allergens

30 Academy of Nutrition and Dietetics (AND) -Resources Medical Nutrition Practice Group; Dietitians in Gluten Intolerance Diseases (DIGID): Evidence Analysis Library (EAL) on CD: Celiac Disease Toolkit: Companion to AND s Evidence-Based Nutrition Practice Guideline Coming Soon! Online Certificate of Training from the Center for Professional Development: Treating Gluten Related Disorders