The Patient on a Unique DietGluten Free, FODMAPs, 7-food Elimination

Justine Turner MD PhD

University of Alberta

Fiona Press RD PhD

Saint Michaels

Financial Interest DisclosureJustine Turner over the past 24 months

Commercial Interest Relationship

Fresenius Kabi Research support

Not relevant to this presentation

CDDW/CASL Meeting Small Group Session Tues 11, 11oo

Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician Role in the CanMEDS framework.)

Communicator (as Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.)

Collaborator (as Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.)

Manager (as Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system.)

Health Advocate (as Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.)

Scholar (as Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.)

Professional (as Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.)

CanMEDS Roles Covered in this Session:

OBJECTIVES

• Discuss the incidence (reality) of these diseases: celiac disease, gluten sensitivity, IBS, EE

• Identify patients who may benefit from these unique diets

• Discuss the nutritional recommendations, and the risk/benefit of these diets

TERMINOLOGY

Adverse Food Reaction

Non-ImmuneImmune

IgE(OAS, hives,anaphylaxis)

non-IgE(FPIES)

Other(physiologic: ?IBS, ?gluten sensitivity)

Toxic(food poisoning)

Cell mediated(contact

dermatitis)

Mixed(EE)

Metabolic(lactose

intolerance)

Pharmacologic(tyramine)

autoimmune(celiac, DH,

gluten ataxia)

Adapted from: Boettcher & Crowe AJG 2013

Are we living in a gluten free world?

GLUTEN FREE DIET

Yes, we are!

A Gluten free world may not be a good thing?

Celiac Disease in 2014

• Common autoimmune enteropathy• Triggered by gluten (wheat, rye, barley)• HLA genes necessary but not sufficient

– 30% population HLA DQ2/8– 1% population have CD– 98-100% of CD patients have HLA DQ2/8

Celiac Disease

• Chronic or recurrent diarrhea

• Abdominal distension• FTT or weight loss• Abdominal pain• Vomiting• Constipation• IBS• Fatigue

• Short stature• Irritability, inattention• Iron deficiency anemia

resistant to Rx• Hepatitis• Arthritis• Headaches• Epilepsy• Dermatitis herpetiformis

CD Presentations

• First degree relatives• Type 1 diabetes• Autoimmune Thyroiditis• Down Syndrome• Turners Syndrome• Williams Syndrome• Selective IgA deficiency

CD AsymptomaticCOMMON

6X

Prevalence

Symptomatic

Celiac Disease

• aTTG screening (?)• Biopsy if positive screen or clinical suspicion

– minimum of 4 specimens with bulb biopsy• HLA DQ2/8 negative predictive value to rule

out diagnosis

CD Diagnosis

• Food allergy is immune mediated• Wheat is a common food allergen

– milk, soy, egg, corn, peanuts more common• More commonly considered than present

– non-IgE symptoms (abdominal pain, rashes...)• Bakers Asthma• Exercise induced anaphylaxis• Allergy test (only) when clinical suspicion

Wheat Allergy

Celiac Disease

Wheat Allergy

Gluten Sensitivity

Time exposure to symptoms

Weeks - years Minutes - hours Hours - days

Pathogenesis Autoimmune (innate and adaptive)

IgE non-IgE

?immune?innate

HLA genetics 97% 30-40% (general population)

50%

aTTG / EMA Usually positive Absent Absent

Enteropathy Usual Absent ?Slight increase IELs

Symptoms IndistinguishableIntestinal and extra-intestinal

Complications long-term without GFD

short-term ?none

Adapted from Fasano et al; NEJM 2012

Gluten and IBS

Bieskierskierski et al AJG 2011

Data shown represent the mean change in symptoms compared at week 1 by independent samples t-test:

overall symptoms (P=0.047)abdominal pain (P=0.016)bloating (P=0.031)satisfaction with stool consistency (P=0.024)tiredness (P=0.001)wind (P=0.053)nausea (P=0.120) .

n=19 n.b. 6 dropoutsn=15 n.b. 3dropouts

Gluten and IBS

(A) Diet effect on stool frequency (P = .04), form, and ease of passage; the effect on stool frequency was greater in HLA-DQ2– or HLA-DQ8–positive patients (P = .019)

(B) Mean bowel movements per day during 14-day baseline and 28-day diet treatment periods in each patient randomized to gluten-free and gluten-containing diets. HLA-DQ2/8–negative patients are indicated by the open symbols

Vasquez-Roque et al Gastro 2013

Gluten Free Diet

• Gluten (Gliadin) is a protein found in grains such as wheat, rye, barley, spelt, kamut, triticale (mix between rye and wheat)

• Oats (Avenalin) – “Gluten Free Oats”• Found in items such as breads, cereals,

pastas, cakes and cookies• Often added to other foods and in many

condiments

Tricky Foods!• Labeling laws have improved but.. not perfect

• Gluten free grains are often contaminated with wheat

• Spices -possible exceptions are chili powder, paprika, cayenne pepper and imitation pepper

• Spices and Seasoning (Mixed) - are not required to carry a list of ingredients. Seasonings should be checked with the manufacturer

• Hydrolyzed Vegetable Protein (HVP)/ Hydrolyzed Plant Protein (HPP) - If the protein source is not labeled, check with the manufacturer

• Separate toaster

• Cross contamination at bulk bins

• Chewing gum/Toothpastes - may contain modified starch

OTHER HELPFUL HINTS/CONCERS

• Medications: Some prescription and non-prescription drugs contain gluten

• Other sensitivities: e.g. milk, fat, nuts, wines, citrus fruit and MSG.

• Vitamins and Minerals:-GF cereals are often not enriched with niacin, riboflavin, thiamin and iron

-choose brown rice, legumes, meat, fresh fruit and vegetables, nuts and seeds.

• Constipation: -Avoiding whole grain products may decrease fibre intake

-choose legumes, fresh fruits and vegetables,seeds and nuts and drinking eight to tencups of fluid per day.

Usual Diet• Breakfast• 1 cup cherrios• 3/4 cup 2% milk beverage• 1 banana• AM Snack• Tim Hortons donut or muffin• Coffee with cream and sugar• Lunch• Meat and Cheese Sandwich with butter and mayo• 1 cup Orange Juice• 1 Pear• PM Snack• Chocolate chip cookies /chocolate bar/chips• Dinner• 3 oz Roast Chicken with BBQ sauce• Uncle Bens Bistro Rice• Green salad- 1 cup greens w/ ½ chopped tomatoes, cucumbers & bell peppers w/ Ranch

Dressing• ½ cup Haagen-Dazs – Brownies and Cookie Dough

Usual DietBreakfast

1 cup cherrios ×3/4 cup 2% milk1 bananaAM Snack

Tim Hortons donut or muffin ×Coffee with cream and sugarLunch

Meat and Cheese Sandwich with butter and mayo ×1 cup Orange Juice1 PearPM Snack

Chocolate chip cookies × /chocolate bar/chipsDinner3 oz Roast Chicken with BBQ sauce?

Uncle Bens Bistro Rice ×Green salad- 1 cup greens w/ ½ chopped tomatoes, cucumbers & bell peppers w/ Ranch Dressing?

½ cup Haagen-Dazs – Brownies and Cookie Dough ×

Rice: WATER, LONG GRAIN PARBOILED RICE, CANOLA OIL AND/OR SUNFLOWER OIL, HYDROLYZED PLANT PROTEIN (SOY, WHEAT), SUGAR, SALT, TOMATO PASTE, FLAVOUR, DEHYDRATED VEGETABLES (RED BELL PEPPER, PARSLEY), CITRIC ACID, SPICES, GUAR GUM, SILICON DIOXIDE, HYDROGENATED VEGETABLE OIL (SOYBEAN), XANTHAN GUM. 

Diana’s Original:SUGAR/GLUCOSE-FRUCTOSE, WHITE VINEGAR, TOMATO PUREE, WATER, SALT, WORCESTERSHIRE SAUCE (Contains malt vinegar [barley], hydrolyzed soy protein, anchovies [fish]), FANCY MOLASSES, XANTHAN GUM, MUSTARD, TURMERIC, SPICES, SODIUM BENZOATE, POTASSIUM SORBATE, OLEORESIN PAPRIKA, ONION POWDER, GARLIC FLAVOUR

Modification for Gluten Free• Breakfast• 1 cup Chex • 3/4 cup 2% milk• 1 banana• AM Snack• Tim Hortons - gluten free macaroons• Coffee with cream and sugar• Lunch• Meat (check for additives)and Cheese Sandwich (gluten free bread) with butter and mayo• 1 cup Orange Juice• 1 Pear• PM Snack• Simply bar/chocolate bar/chips• Dinner• 3 oz Roast Chicken with BBQ sauce (check ingredients!)• Uncle Bens Wild Rice• Green salad- 1 cup greens w/ ½ chopped tomatoes, cucumbers & bell peppers w/ Oil and Vinegar• ½ cup Haagen-Dazs – Vanilla

Approx 120 000 Canadians are diagnosed with IBS each year: can diet help?

Low FODMAPs DIET

FODMAPs NOT Gluten

Bieskierskierski et al Gastro 2013

Double blind crossover trial NCGS (n=37)

Individual responses in mean overall symptom severity score on 2 weeks of low FODMAP diet improved p < 0.0001

No further change on 7-day Gluten diets

FODMAPs and IBS

Staudacher H M et al J Nutr 2012

After 4 weeks of habitual dietcontrol n=22intevention n=19

*p<0.05

FODMAPs post-colectomy

Croagh et al IBD 2007

Obsevational 15 patients (n=8 pouchitis)

Without pouchitis stool frequency improved on low FODMAP diet p < 0.0001

FODMAP

Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols

• IBS symptoms (diarrhea, bloating, abdominal pain, gas) secondary to: poor absorption, osmotic load and rapid fermentation of these short chain CHO

• Need to eliminate other causes of the above symptoms including: caffeine, alcohol, excess fat and poor eating habits

• Leaders- Monash University in Australia

Food type Free Fructose Lactose Fructans Galactans Polyols

Fruits Apple, cherry, mango, peach, pear, watermelon, canned fruit in pear juice

Persimmon, Nectarinewatermelon

Apple, apricot, pear, peach, avocado, blackberries, cherry, lychee, nectarine, peach, pomegranate, plum, prune, watermelon

Vegetables Asparagus, artichokes, sugar snap peas

Asparagus, beetroot, broccoli, brussels sprout, cabbage, chicory, fennel, garlic, leak, onion, snow peas

BeetrootBroccoliChicory leavesFennel bulbWhite onionRadicchio lettuce

Cauliflower, mushroom,snow peasSweet corn

Grains and Cereals Wheat, rye, barley,

Nuts and seeds Pistachios + Cashwes

Milk and Milk products

Milk, yogurt, ice cream, custards, soft cheeses made from cow, sheep, goat

Legumes Beans, lentils, chickpeas

Legumes, lentils, chickpeas

Other Honey,  agave syrup, foods with glucose‐fructose (HFCS)

Chicory drinks, inulin, FOS

Sorbitol, mannitol, maltitol, xylitol, isomalt

Adapted from Suzanne Hansen presentation - Nov 2012

Nutritional Considerations

Effects on the microbiotic milieu of the colon?

- Decrease in prebiotics (↓bifidobacteria, ↑E. Coli ect)

- Decrease in SCFA (e.g. butyrate)Lowers the fibre content of the dietLowers the micronutrient profile of the diet

Usual Diet• Breakfast• 1 cup cherrios x• 3/4 cup 2% milk x• 1 banana• AM Snack• Tim Hortons donut or muffin x• Coffee with cream and sugar x• Lunch• Meat and Cheese Sandwich with butter and mayo x• 1 cup Orange Juice ?• 1 Pear x• PM Snack• Chocolate chip cookies X/chocolate bar?/chips • Dinner• 3 oz Roast Chicken with BBQ sauce ?• Uncle Bens Bistro Rice X• Green salad- 1 cup greens w/ ½ chopped tomatoes, cucumbers & bell peppers w/ Ranch

Dressing?• ½ cup Haagen-Dazs – Brownies and Cookie DoughX

Low FODMAP DietFruit Vegetables Milk Products Grains and Cereals Other

BananaBerries (except blackberries)Dragon fruitCantaloupeGrape ?GrapefruitHoneydew melonKiwifruitCitrus fruitsPineappleRhubarb

AlfalfaBamboo shootsBok choyCarrotCeleryEggplantEndiveGreen beansLettuceParsnipPotatoPumpkinBell  peppersSpinachSquashTomatoTurnipYamZucchini

Lactose free milkRice drinkSoy drinkHard cheeses Brie CamembertLactose‐free yogurtButter

Wheat In moderationSpelt breadGluten‐free breadsGluten ‐free cereals or corn flakes, rice krispiesRiceOatsPolentaQuinoaCorn

GlucoseArtificial sweeteners –Aspartame, sucraloseMaple syrupGolden syrup

Modifications Required•Breakfast•1 cup oatmeal•3/4 cup lactose free milk•1/2 banana•AM Snack•Tim Hortons- 1/2 gluten free macaroon•Coffee with lactose free milk and sugar•Lunch•Meat and Brie Cheese Sandwich (GF) with butter and mayo•1/3 cup Orange Juice• ½ cut carrot and celery•PM Snack• Gluten free chocolate chip cookies /chocolate bar/potato chips•Dinner•3 oz Roast Chicken with BBQ sauce (tomato/glucose based)•Boiled Rice•Green salad- 1 cup greens w/ ½ chopped tomatoes, cucumbers & bell peppers w/ Oil and Vinegar Dressing•½ cup Sorbet with ½ cup cantaloupe

7-Food Elimination Diet & EE

6-Food Elimination Adult EEOne Year Later

Lucendo et al J Allergy Clin Imm 2013

73% of 67 patients responded to diet (6 weeks)25 patients followed one year after diet trigger completely eliminated (single rechallenge tests)

• Goal- to eliminate the most allergenic foods to minimize exposure to allergens that may be contributing to symptoms

• Pediatrics- protein-hydrolysate formula (elemental formulas- Peptamen, Vivonex, Vital, EO28 Splash, Neocate Jr)

• Breast feeding mothers may also need to restrict their diets

for eosinophilic esophagitis (EE), eosinophilic gastroenteritis (EG) and eosinophilicesophagitis (EE)

7 Foods to be Eliminatedfor 6 weeks

• Wheat• Dairy/Cow’s Milk• Soy• Peanuts• Tree Nuts• Eggs• Seafood

Micronutrient Considerations

• Calcium- 1000 mg (500mg elemental bid)• Vitamin D- 1000 mg

(due to the lack of milk products and other fortified drinks e.g. soy)

-Wheat-based grain products are good sources of B-vitamins, zinc, and iron

-Eggs are a good source of protein, folate, vitamin b12, zinc & iron

Usual Diet• Breakfast• 1 cup cherrios x• 3/4 cup 2% milk x• 1 banana• AM Snack• Tim Hortons donut or muffin x• Coffee with cream and sugar x• Lunch• Meat and Cheese Sandwich with butter and mayo x• 1 cup Orange Juice• 1 Pear• PM Snack• Chocolate chip cookies x/chocolate bar ?/chips• Dinner• 3 oz Roast Chicken with BBQ sauce ?• Uncle Bens Bistro RiceX• Green salad- 1 cup greens w/ ½ chopped tomatoes, cucumbers & bell peppers w/ Ranch

Dressing?• ½ cup Haagen-Dazs – Brownies and Cookie DoughX

Modifications• Breakfast• ¾ cup oatmeal prepared from uncontaminated oats with raisins and brown sugar• 1 cup alternative milk beverage (rice, hemp, oat, coconut beverage).• 1 banana• AM Snack• ½ cup applesauce• ½ cup of trial mix-dried fruit with pumpkin and sunflower seeds• Lunch• 1 cup chili or bean soup (Dairy-free)• 2 rice cakes• Carrot and Celery Sticks with2 tbsp vegan dressing or hummus• 1 Pear• PM Snack• 1 cup alternative milk beverage (rice, hemp, oat, coconut beverage).• Corn Chips with salsa and guacamole• Dinner• 3 oz Roast Chicken with gluten free BBQ sauce• 1 cup brown Rice • Green salad- 1 cup greens w/ ½ chopped tomatoes, cucumbers & bell peppers w/ oil & vinegar

dressing• ½ cup mixed Berries with sorbet

Help!

In Conclusion

Provided the medical background to justify prescribing these unique diets

Provided the basic nutritional recommendations to appreciate the complexity of these diet restrictions