Coeliac disease

1. Coeliac disease An increasing problem? Myrtle Walsh Dietitian

2. Prevalence • Recent studies suggest 1% population have positive coeliac serology. 2003 study in England – 1.2% • Also shown that 0.5 – 1% of Europe, S. America,U.S.A., Australasia may have undetected coeliac disease • Higher in first and second degree relatives • Bristol study in 2004 in children – 1% • In diabetic children incidence recorded as high as 3% • Clinically diagnosed – 0.27% [ 1 to 8]

3. Diagnosis • Early data pre-1990 for classical coeliac disease may not be applicable to contemporary coeliac disease • Changes in clinical practice/dramatic increase in knowledge of pathogenesis, making coeliac disease the best understood “autoimmune” disorder

4. Classical Clinical symptoms and signs eg. weight loss, diarrhoea,anaemia Green et al 2005 Contemporary Positive serology eg. EMA, tTG, AGA [include IgA] Endoscopy/duodenal biopsy Diagnosis

5. Presentation • Can be diagnosed at any age • Most common in early childhood 9 – 24 months • Or in the 3rd or 4th decade of life • In children 1:1 sex ratio • In adults twice as many females to males

6. Symptoms • Diarrhoea, steatorrhoea, weight loss, fatigue, anaemia – in severe cases [classical] • Most have – abdominal discomfort, bloating, indigestion, non-gastrointestinal – or no symptoms at all [contemporary] Study by HIN et al, in primary care, patients presenting with TATT and anaemia

7. Other factors • Osteoporosis, low bone density,fracture risk • Anaemia, subnormal nutritional status • Malignancy, mortality • Low fertility Vasquez et al – x3 increase in fracture risk West et al – small increased risk Suggested all coeliac patients should have DEXA screening for osteoporosis More studies required? before universally recommended

8. Dietary Implications-exclusion of Gluten • Gluten is found in WHEAT, BARLEY and RYE • Gluten free is not synonymous with wheat free • Some controversy regarding OATS, not advised in children but studies so far indicate adults may include

9. Sources • Main staple foods – bread, flour, cereals, pasta, pizza, biscuits, crackers, cakes, couscous • Sauces, soups, gravy, coatings, batters, pre-packed or tinned foods, confectionary, snacks • Medications

10. Changes - “gluten free” • For the first time in Europe a law on labelling is being created for gluten-free foods • It is not possible in practice to test for a zero level of gluten • The standard for this labelling is set by a body called Codex Alimentaris [under WHO] • Previously – 200mg gluten/kg or 200ppm. In July, 08 – dual standard now; 1] < 20ppm. Only those foods can be labelled gluten-free [can include pure uncontaminated oats] 2] 20-100ppm to be labelled very low gluten • New legislation published in January, 09. There will be a 3 year transitional period to allow manufacturers to make the changes.

11. Availability • Prescribable products – staple foods only [note there will be changes to these products to comply with Codex Alimentaris] • Increasing supermarket products – improved labelling since November 2005 legislation and now within 3 years further improved labelling again • Use of alternative products – eg corn, rice and potato based COST

12. Guidance to prescriptions • Changes by some PCTs • Coeliac UK recommendations • Items are estimated in units, e.g. 400g bread = 1 unit 250g pasta = 1 unit

13. Coeliac UK • Support organisation, research • Up-to-date information on which foods suitable • Production of annual food directory – updates via mail, e-mail and website • List of manufacturers • Medication, local addresses, holiday information, foreign travel and “language” cards

14. Challenge • In diagnosis in infants possibility of gut immaturity • Reintroduction of gluten – by food or with gluten powder [ 2-4slices bread/10g-20g / day] • 2-3 months duration • Re-biopsy/ EMA/ tTGA test • Or use of genotype test – HLA-DQ

16. Irritable Bowel Syndrome [IBS] A dietary problem? Myrtle Walsh

17. Prevalence • Affects up to 20% of Western populations • Accounts for up to a third of referrals to a Gastroenterologist and a large proportion of GP visits [12%] • 11-13% adults present with IBS, but estimated that only 25% of those with the condition seek help

18. Definition • No specific pathophysiological marker • Can present with a combination of symptoms • Functional bowel disorder • Exclusion of organic disease

19. Rome 11 CriteriaThompson et al, 1999 • Abdominal pain relieved by defecation or associated with change in frequency or consistency of stool and • An irregular pattern of defecation for at least 2 days a week[3 or more of]: • Altered stool frequency • Altered stool form[hard or loose] • Altered stool passage • Passage of mucus • Abdominal bloating or feeling of distension

20. Possible Causal Contributors • Altered bowel motility • Visceral hypersensitivity • Psychological factors • Imbalanced neurotransmitters • Altered intestinal flora • Increased cytokine production • Poor general diet/poor balance of fibre • Large consumption of irritants • Food Intolerance

21. Management of IBS • No universally agreed approach Current treatment, following diagnosis, may combine: • Treatment of GI symptoms: use of medication, eg antidiarrhoeal, smooth muscle relaxants exploring dietary triggers, dietary manipulation • Treatment of affective disorders/psychological symptoms: strategies to cope with stress, reassurance, and where appropriate, drug treatment for anxiety and depression

22. Dietary intervention in IBS • Lack of robust research • Systematic review 1980-99 • Few RCT – mainly concentrated on fibre modification • Majority observational studies Burden S [2001]J Hum Nut, vol14 Wald [2000] lists dietary modification as an essential element

23. Evidence 1999-2004 • No further significant trials • Can diet influence – intestinal motility, fermentation in the colon, intestinal immunity? • In Oxfordshire [symptom based] – audit in 2001 led to development of “The Oxford Approach”- nationally available advice • Repeat review in Nov. 2003 showed diet improved symptoms in >60% of patients [further review planned]

24. The Current Approach • Step 1 and 2 diet advice booklet – available for Drs and GP’s • Step 3 – with dietetic intervention. Symptoms/assessment of patient/detailed diet history • Exclusion diets – very basic diet= no wheat, corn, yeast, dairy, processed food for 2 weeks, followed by staged re-introduction

25. Step 3 • Meal pattern, emotional state when eating, nutritional content • Fibre content, NSP • Fermentable carbohydrate/resistant starch • Caffeine – tea/coffee/fizzy drinks • Sorbitol and fructose – sorbitol mixtures • FOS

26. Other dietary components • Probiotics - continuing research. Can benefit many • Alcohol – moderation • Linseeds – useful in constipation/ alternating constipation+diarrhoea/wind and bloating

27. Exclusion diets • Final dietary step • Only reliable method for investigating food intolerance [ prevalence uncertain] • Threshold effect/dose response • Challenge beliefs/ self-imposed restrictions • Can be delay in response to food Require patient to be motivated/appropriate, can cause financial and family burden. It is very intensive.

28. Summary Patient presents with eg. Loose stools + abdominal pain, suffered on and off - 6 mths  Eliminate organic causes/Rome 11 criteria  Investigate other causes further : Diagnose IBS  Treat symptoms [GI/psych] : Explore dietary  intervention Referral for dietetic advice

29. Assessment &Advice • Questioning and qualitative assessment • Lifestyle factors/meal frequency • Restrictions? • Specific advice to presenting symptoms, and modifications in food choice

30. NICE Guidelines due to be produced in 2008