11/5/2018 FINDING SLIDES FOR TODAY’S WEBINAR COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS November 5, 2018 www.villanova.edu/COPE Gluten-Related Disorders: Click on Alessio Fasano MD How to Distinguish Facts from Fantasies webinar description page Moderator: Lisa Diewald MS, RD, LDN Program Manager MacDonald Center for Obesity Prevention and Education Nursing Education Continuing Education Programming Research OBJECTIVES DID YOU USE YOUR PHONE TO ACCESS THE WEBINAR? 1.Recognize the differences between celiac If you are calling in today rather disease, non-celiac gluten sensitivity and than using your computer to log on, wheat allergy. and need CE credit, please email 2.Discuss the epidemiology of celiac cope@villanova.edu and provide disease and why prevalence is increasing your name so we can send your 3.Identify the role of the gut microbiome and certificate. intestinal permeability in autoimmune disease CE DETAILS CE CREDITS • Villanova University College of Nursing is accredited as a • This webinar awards 1 contact hour for nurses and 1 provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation CPEU for dietitians • Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education • Suggested CDR Learning Need Codes: 2000, 5110, 5220 (CPE) Accredited Provider with the Commission on Dietetic Registration and 6000 • The American College of Sports Medicine’s Professional Education Committee certifies that Villanova University • Level 2 College of Nursing Continuing Education, Center for Obesity Prevention and Education (COPE) meets the criteria for official ACSM Approved Provider status (10/2018-9/2021). Providership #698849 • CDR Performance Indicators: 8.1.2, 8.1.5, 8.3.1, 8.3.6 1
11/5/2018 GLUTEN AND GLUTEN-RELATED DISORDERS: DISCLOSURE HOW TO DISTINGUISH FACTS FROM FANTASIES The planners of this program have no conflicts of interest to disclose. Alessio Fasano, MD Chief of Pediatric Gastroenterology Any presenter conflict of interest was resolved prior to the planning of this and Nutrition program. Any additional disclosure information will be provided to participants during the live activity. The Nurse Planner has reviewed the presentation and Mass General Hospital for Children determined that it is evidence-based, balanced and unbiased Professor of Pediatrics Harvard Medical School Accredited status does not imply endorsement by Villanova University, COPE or the American Nurses Credentialing Center of any commercial products or medical/nutrition advice displayed in conjunction with an activity. Conflict of Interest Disclosure Celiac Disease And Other Alessio Fasano, MD Gluten Related Disorders: I disclose the following financial relationships with commercial entities that produce health care related products or services relevant to the content I am planning, developing, or presenting: How To Distinguish Company Relationship Content Area Facts From Fantasies Alba Therapeutics Stock Holder Alternative treatments to gluten free diet for celiac patients Alessio Fasano, M.D. Inova Diagnostics Consultant W. Allan Walker Chair in Pediatric Gastroenterology and Nutrition Innovate Consultant Professor of Pediatrics Harvard Medical School Biopharmaceuticals, Inc. Mucosal Biology and Immunology Research Center Mead Johnson Nutrition Speaking Agreement And Center for Celiac Research And Treatment Massachusetts General Hospital for Children The Source Supporting The Controversy On Who Should Be On A GFD GFD For Everybody Only People With Celiac Disease Everybody 2
11/5/2018 The Epidemics Of Gluten The Epidemics Of Gluten Related Disorders Related Disorders - Quality of gluten: GE grains - Quality of gluten: GE grains - Quantity of gluten - Quantity of gluten - Gluten cannot be digested - Gluten cannot be digested Kasarda D. J Agric Food Chem. 2013;61: Kasarda D. J Agric Food Chem. 2013;61: 1155–1159. 1155–1159 GMO Grains The Epidemics Of Gluten Related Disorders - Quality of gluten: GE grains + - Quantity of gluten - Gluten cannot be digested T. turgidum AABB Aegilops tauschii DD T. aestivum AABBDD 28 chromosomes 14 chromosomes 42 chromosomes 100,000 genes 50,000 genes 150,000 genes 3
11/5/2018 The Epidemics Of Gluten Related Disorders - Quality of gluten: GE grains - Quantity of gluten - Gluten cannot be digested Kasarda D. J Agric Food Chem. 2013;61: 1155–1159 Structural Characteristics of Alpha-Gliadin What is so Special About Gluten? Shan L et al, Science . 2002; 297:2275-9. Lammer K et al, Immunology . 2011;132:432-40 Gliadin Glutenin Lammer K et al, Gastroenterology Maiuri et al. Scand J 2008;135:194-204. Gastroenterol . 1996; 31:247-53. Gluten (gliadin+glutenin) The Banana Babies Celiac Disease 1 st case of CD at UMB: 1938 WK Dicke, 1905 - 1962 4
11/5/2018 Gastrointestinal Manifestations Celiac Disease as a Unique (“Classic”) Model of Autoimmunity Most common age of presentation: 6-24 months • The only autoimmune disease in which specific MHC class II HLA (DQ2 and/or DQ8) are present in • Chronic or recurrent diarrhea • Abdominal distension >95% of patients; • Anorexia • The auto-antigen (tissue Transglutaminase) is • Failure to thrive or weight loss known; • Abdominal pain • Vomiting • The environmental trigger (gluten) is known; • Constipation • Elimination of the environmental trigger leads to • Irritability a complete resolution of the autoimmune process Rarely : Celiac crisis that can be re-ignited following re-exposure to gluten The Clinical Manifestations of Celiac Disease Non Gastrointestinal are More Heterogeneous Than Manifestations Previously Appreciated Most common age of presentation: older child to adult Dermatitis Herpetiformis • Iron-deficient anemia • resistant to oral Fe • Dental enamel hypoplasia • Hepatitis of permanent teeth • Arthritis • Osteopenia/Osteoporosis • Epilepsy with occipital • Short Stature calcifications • Delayed Puberty Listed in descending order of strength of evidence A. Fasano, N Engl J Med 2003;348:2568-70. The Epidemics of Celiac Disease The Epidemics Of Celiac Disease: 0.93% Which Additional Factors are Driving this Epidemics? 0.45% 0.21% - Quality of gluten; - Quantity of gluten; - Breast Feeding; - Timing of gluten introduction - Maturity of gut functions influencing Ag trafficking and handling: - GALT - PRRs - Mucous production - Barrier function - Changes in microbiome composition. 5
11/5/2018 Take Home Messages • Window of tolerance concept not supported anymore; • Breast feeding in general or introduction of gluten while breast feeding showed no protective effect on CD onset in at-risk infants; • Early introduction (16 weeks) of gluten traces to potentially induce tolerance did not protect against CD in at-risk infants; • Delaying the introduction of gluten in at-risk infants does not prevent CD but merely postpones its onset by approximately 8 months (significant difference at 2 years FU that disappeared by 5 years FU); • GI infections during the first year of life seems influential in increased the risk of CD onset; • High-risk HLA profiles seems to be the most influential factor predictor of increased risk of CD onset; The high prevalence of CD among the study cohort suggests that the • Published on October 2, 2014 CD epidemics continues. The Epidemics Of Celiac Disease: Which Additional Factors are Driving this Epidemics? - Quality of gluten; - Quantity of gluten; - Breast Feeding; - Timing of gluten introduction - Maturity of gut functions influencing Ag trafficking and handling: - GALT - PRRs - Mucous production - Barrier function - Changes in microbiome composition. Key Open Questions Concerning Not Only Celiac Disease Celiac Disease: • Best diagnostic strategies? Endoscopy yes/no for diagnosis? • • How to properly follow up CD patients? • Should CD patients be actively screened for other autoimmune diseases? • How to manage CD patients with discrepancies between serology and histology? • Are POC tests useful/appropriate for diagnosis and/or management of CD? • Is the GFD highly effective in controlling CD? • How to properly check for gluten cross-contamination? • Are there any alternative/complementary treatments to the GFD at the horizon? 6
11/5/2018 Gluten Free Market How Many People in the US Are Embracing a GFD?: Percentage of U.S. Adults Trying to Cut Down or Avoid Gluten in Their Diets Reaches New High in 2016, Reports NPD For the American general population adopting a gluten-free diet is becoming an increasingly popular solution. The market for gluten-free food and beverage products grew at a compound annual growth rate of 28 percent from 2004 to 2011, to finish with almost $6.7 billion in retail sales last year. By the end of 2016 the market is expected to reach about $14.6 billion in sales. The Fad Factor of the GFD The Gluten Free Diet: The Gluten Free Diet: Why People in the US Embrace a GFD?: Not Only Celiac Disease Not Only Celiac Disease Approx 7M Approx 400,000 Approx 9M Approx 50M Approx 24M Based on internet interview users age 18y+ who eats GF food 7
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