What is Celiac Disease? • Celiac disease is a genetically inherited, autoimmune reaction to the gluten protein found in wheat (gliadin), rye (secalin), and barley (hordein)

C li Celiac Disease Di and d th the A Aging i Ad lt Adult Shannon Longhurst, RD, CD UW-Extension Nutrition and Aging Conference 2010

The Oat Controversy • Studies have proven that most commercial brands of oats are contaminated with wheat • Specialty p yg grown and tested g gf oats are available • Oats have been proven to enhance nutritional QOL • Limit to 50g dry oats/day

How Can People Carry the Celiac Genes and Never Develop the Condition?

• Three factors must be present for celiac presentation: genetic disposition (HLA-DQ2 and HLA-DQ8), ingestion of gluten, and: – Some type of environmental trigger. There are many speculations, but pregnancy, surgery, infections, and even psychological stress can play a role—all instances when the immune system is susceptible – In the older adult, viral infections are suspected to be the #1 trigger

• When gluten is ingested ingested, the body mistakes the gluten protein as a foreign substance and creates antibodies meant to attack gluten • These antibodies instead attack the lining of the small intestine, damaging the villi and preventing the body from properly digesting nutrients

Intestinal Damage

Healthy Villi

Celiac Disease

THIS MEANS…. • Given the genetic predisposition, eating gluten like most Americans do,

• THE GENES CAN BE TURNED ON AT ANY AGE, INCLUDING 60-90+yo!! • Many older adults, however, have untreated CD for many years, not unlike the general population (average length of time from symptoms to dx is 7-11yrs—if symptoms are even present).

1

Symptoms

Childhood CD

• Over 70% of people with celiac disease are asymptomatic—they typically don’t find out they have a problem until nutrient deficiencies or other health problems occur later in life (such as osteoporosis, anemia, or infertility) • Because all vitamins and minerals eaten affect every system of the y, there are manyy different symptoms y p related to celiac disease body, and are individual; in fact,there are over 400 documented symtpoms. The “classic” symptoms include gastrointestinal symptoms (bloating, diarrhea, ect.) weight loss, and lactose intolerance • CD used to be considered a pediatric condition that could be outgrown—symptoms of FTT make CD easier to dx in children – Banana and rice babies—perhaps some of your clients followed this in the past. Be sure to question client’s hx carefully—”Have you ever had to follow a special diet?”

Not So Obvious In the General Population of Older Adults

Not so obvious but… • Celiac dz is found to be 2.5x more prevalent in adults ages 60+ • Possible reasons include: – Increased awareness of both professionals and lay people (NIH Consensus), leading to increased diagnosis – Increased self-advocacy – More widespread use of interdisciplinary health care teams – Older adults have been carrying the genes and eating gluten for years and eventually the “time bomb” goes off

Other Conditions Associated w/CD

CD Facts • It is estimated that 1:100 Americans have CD, 97% of whom are undiagnosed – 1st degree relatives of those w/CD have a 4-12% chance of developing CD – 2nd degree relatives also have an increased prevalence – A relative w/ an autoimmune dz has up to a 25% chance of having CD – Latent CD—carry genes, may or may not express them, but given the needed conditions can occur at any time—studies w/family members of dx celiacs tested every 5 yrs increased dx rate – Higher prevalence in European descendants but has been dx in people of African, Hispanic, Asian, and middle eastern descent

• • • • • • • • •

Dermatitis Herpetiformis—100% Collagenous Colitis—20% Lymphocytic Colitis—14.8% Anti-Phospholipid Syndrome-14% T1DM—8-10% Down’s Syndrome—5-12% Addison’s—7.9% Cardiomyopathy—5.7% CD is often highly associated with other autoimmune and medical disorders, including but not limited to: psoriasis, thyroid dz, Sjogren’s,autoimmune liver dz, alopecia areata, lupus, rheumatoid arthritis, fibromyalgia, aphthous stomatitis, MS, Turner syndrome, Williams syndrome, and IgA deficiency

2

Why CD is Easily Overlooked in Older Adults

• GI motility complaints are common • Weight loss is assumed (wrongly!) to be a normal process of aging or accompanies other health problems, or because an individual is overweight, CD is dismissed • Problems such as osteopenia/osteoporosis, anemia (B12, folate, or Fe deficiencies), Vit. D deficiency, depression, dementia, rheumatoid arthritis, and thyroid dysfunction as often associated with old age alone, as the body decompensates • Symptoms in elderly may be more subtle

The Good News is… • As long as gluten is eliminated from the diet, THE INTESTINES WILL HEAL! • The ONLY CURE for celiac disease is lifelong, strict elimination of the offending gluten proteins from the diet and from sources outside the diet • THE GLUTEN-FREE DIET IS A MEDICALLY NECESSARY DIET, NOT A FAD!!! • It may take up to a year for symptoms to subside if the intestines are severely damaged • Amounts as small as 20 ppm of gluten (1/8th tsp flour) can damage the intestines, even if no symptoms are present

Long-term Consequences of Gluten Consumption • People w/CD have twice the risk of developing malignancies than the general population (esophageal carcinoma, small intestinal adenocarcinoma, non-Hodgkin’s lymphoma thyroid cancer lymphoma, cancer, and melanoma) • However, with the exception of nonHodgkin’s lymphoma, five years of compliance on a gf diet reduces the risk to that of the general population

Diagnosing CD • Detailed hx and physical exam • Serological testing: The most accurate are the EMA and tTG. If IgA deficiency is present, test IgG-EMA and IgGtTG • Gold standard is endoscopy and biopsy of small intestine (w/multiple samples) • Cheek swabs can determine if a person carries the gene but does not provide definitive dx • Stool tests have no scientific evidence backing up accuracy---everyone who eats gluten will naturally have SOME gluten antibodies in the stool

• YOU MUST BE CONSUMING GLUTEN PRIOR TO TESTING!!!!

Celiac Disease Vs. Gluten Intolerance Celiac Disease • Autoimmune disorder • Innate and adaptive immune systems involved • Multiple tests available for diagnosis • Strict gluten-free lifestyle necessary • Dire consequences with dietary indiscretion

Gluten Intolerance/Sensitivity • Non-allergic, non-autoimmune reaction • Only the innate immune system is involved • No tests available for dx; dx is based on exclusion criteria and trial of gf diet • Level of tolerance varies with symptoms—no intestinal damage, just the discomfort associated with ingestion • Strict gluten-fee diet not necessary in all cases d/t some tolerance in certain individuals

Remember… ONLY A GLUTENFREE LIFESTYLE WILL CURE CELIAC DIEASE!!

3

Reading Labels • The Food Allergen Labeling and Consumer Protection Act of 2004 required wheat ingredients to be clearly labeled on the package as of 1/1/06 • Voluntary gluten-free labeling law in process—products must test below 20ppm* *Wheat starch and uncontaminated oats are allowed as ingredients as long as

Gluten-Containing and Safe Ingredients (See Handouts)

total serving amount is