Beyond the Gluten-Free Diet: What Foods Are Right for Me?

Name: Beyond the Gluten-Free Diet: What Foods Are Right for Me?
Uploaded: 2017-07-27T22:40:00+00:00
Duration: PTM42S18
Channel: Arron Lawson
Description: Beyond the Gluten-Free Diet: What Foods Are Right for Me?

Beyond the Gluten-Free Diet: What Foods Are Right for Me?
Laurie A. Higgins, MS, RD, LDN, CDE Pediatric Nutrition & Diabetes Educator Joslin Diabetes Center Karen Y. Warman M.S.R.D. Pediatric Nutrition Educator Boston Children’s Hospital

Disclosures Laurie A. Higgins, MS, RD, LDN, CDE - No disclosures
Karen Y. Warman M.S.R.D.

Objectives Understand the nutrition pitfalls of the gluten-free diet.
Discuss additional intolerance if you are symptomatic on the gluten-free diet Identify when you need to seek additional help from a dietitian.

Common Nutritional Deficiencies in Newly Diagnosed Celiac Disease
Anemia Iron, Folate, Vitamin B12 12 to 69% patients at anemic at diagnoses 78 to 98% adults will respond to the GFD Fat Soluble Vitamins – A,D,E, and K Calcium, Phosphorus & Vitamin D Lactose Intolerance Diet low in calcium, and vitamin D GDF diet is low in fiber and enriched foods

Results of 2005 GF Diet Survey: % of people with celiac disease meeting recommended amounts of nutrients 47 volunteers who provided a 3-day food record Records were assessed for daily intakes of calories, %of calories from carbohydrates, dietary fiber, iron, calcium, and grain food servings. Recommended amounts of fiber, iron, calcium and grain servings are as follows: Women (n = 39) Fiber (46%) Grain foods servings (21%) Iron (44%) Calcium (31%) Men (n = 8) Fiber (88%) Grain foods servings (63%) Iron (100%) Calcium (63%) Thompson T, Dennis M, Higgins LA, Lee AR, Sharrett MK. Gluten-free diet survey: are Americans with coeliac disease consuming recommended amounts of fibre, iron, calcium and grain foods? Journal of Human Nutrition and Dietetics. 2005;18(3):163-9.

Conclusions of GF Diet Survey Study
More emphasis is needed on the nutritional quality of the GF diet (especially for women) as it concerns fiber, iron and calcium Eat 6-11 servings (depending on calories) of GF grain foods daily, choose whole or enriched Increase non-grain food sources of Iron & B vitamins Consume 3 servings/day* of lowfat or nonfat GF dairy foods, or calcium-rich and vitamin D fortified, non-dairy foods Consider GF vitamin/mineral, calcium and vitamin D supplements, as recommended. *depending on individual needs Thompson et al, JHND 2005;18:

USDA 2010 Dietary Guidelines
Build a Healthy Plate Make half your plate fruit & vegetables Eat red, orange, and dark green vegetables Choose skim or 1% (lowfat) milk Make a least half your grains whole Vary your protein choices Choose seafood twice a week Add beans (legumes) for a natural source of fiber and protein Keep your meat & protein portions small

USDA 2010 Dietary Guidelines
Cut back of foods high in solid fats, added sugars, and salt Choose foods & drinks with little or no added sugars Look out for salt (sodium) in processed or prepared foods Eat fewer foods that are high in solid fats

Facts on Fiber Undigested, unabsorbed part of plants, found in grains, legumes, fruits, vegetables, nuts and seeds Deficient in most American diets Helps normalize blood sugar and insulin levels Helps with bowel motility – diverticular disease, certain cancers Decrease risk of heart disease with a high fiber diet Helps fill you up on fewer calories – satiety Soluble: helps lower total cholesterol & LDL Insoluble: may help prevent constipation & diverticulosis Increasing fiber should be gradual and drink plenty of fluids

General Fiber Recommendations
Age Fiber (grams/day) Women < 50 25 Women > 50 21 Men < 50 38 Men > 50 30 14 grams Fiber/1000 calories 1800 calories = 25.2 grams fiber per day 2400 calories = 34 grams fiber per day Dietary Reference Intakes Released for Carbohydrates, Fats, Protein, Fiber and Physical Activity. Dietetics in Practice, American Dietetic Association, Fall 2002.

General Fiber Recommendations
Age Fiber (grams/day) Less than 12 months Not determined Children 1-3y 19 Children 4-8y 25 Males 9-13y 31 Males 14-18y 38 Females 9-13y 26 Females 14-18y Institute of Medicine of the National Academies. Dietary Carbohydrates: Sugars and Starches. Dietary Reference Intakes: The essential guide to nutrient requirements. Washington D.C.: 2006: 536.

How to get 25-30 grams Fiber in a Day!
Choose GF grains whole grain Add 2-3 servings of fruit to daily diet Add 2-3 servings of vegetables to your day

Go Slow Increase Gradually
Fermentation by bacteria Potential binding with minerals Increase gradually to enhance tolerance Increase water intake Limit intake to appropriate age group Too much fiber can cause, gas, diarrhea, and or constipation

Fiber Content: Gluten Free Grains & Flours

Fiber & Vitamin Fortification
in GF Foods Most GF cereals, pasta and bread are not enriched and are low in: Dietary fiber Thiamin (B1) Riboflavin WHAT ARE THEY MADE FROM? Reformulation of products by some GF food companies are higher in fiber and nutrients. Try to purchase enriched products. Niacin Iron Folate

Sources of B Vitamins Riboflavin (B2)* Niacin (B3)* Thiamine (B1)*
Best: enriched GF grains and flours, pork Good: soy milk, peanuts, orange juice, legumes and watermelon GFD: legumes (peanuts, beans, soy) products Riboflavin (B2)* Best: enriched grains, eggs and meat Good: liver, mushrooms, spinach and green leafy vegetables, broccoli, asparagus, milk, and cottage cheese GFD: eggs, meats, green leafy vegetables, broccoli, milk and milk products Niacin (B3)* Best: enriched grains, beef, chicken, turkey, fish (tuna, halibut, salmon) Good: peanuts, asparagus GFD: animal proteins, peanuts and asparagus *Main source in the American diet is in the enriched flours, breads, crackers, and breakfast cereals

Sources of B Vitamins B6 Best: meat, fish and poultry
Good: banana, avocado, potatoes, sunflower seeds GDF: meat, fish, poultry, banana, avocado, and sunflower seeds Folate* Best: fortified breakfast cereals and other grain products, legumes, and vegetables (spinach and leafy greens, sprouts, romaine lettuce, cabbage, etc. Good: liver, broccoli, beets, sunflower seeds, legumes, orange juice GFD: vegetables, and leafy greens, legumes (lentils) B12 Best: animal products (meat, poultry, seafood, and eggs) Good: milk and milk products 10-20% of older adults are at risk of B12 deficiency because they lose the ability to absorb (decrease intrinsic factor) the vitamin Vegans – need a reliable source

B Vitamin Content in GF Flours (1C)
Folate Amaranth 0.11 0.28 1.7 0.30 66 Buckwheat 0.50 0.23 7.4 0.70 65 Millet 0.76 0.48 2.8 ---- Quinoa 0.22 0.44 3.3 0.25 55 Sorghum 0.46 0.27 5.6 1.13 38 Teff 0.51 0.14 1.9 97 Wheat whole-grain 0.54 0.26 7.6 0.41 53 Wheat, white, enriched 0.91 0.62 0.06 229 USDA National Nutrient Database -

Bone Disease At celiac disease diagnosis: ~10-30% have osteoporosis
~40% have osteopenia Vitamin D and Calcium deficiency result in greater risk of bone loss, fractures, falls, and perhaps infections, autoimmune diseases and cancer Meyer D, AJG 2001; McFarlane et al., Gut 1996; West et al., Gastroenterology 2003

Key Points: Celiac Disease & Bone Metabolism
Vitamin D and calcium deficiency are common across the United States – ½ of Americans have suboptimal levels Vitamin D and Calcium absorption may not completely normalize with GFD Patients with celiac should have adequacy of the Vitamin D and Calcium regimen checked after 6 months of GFD

Recommended Dietary Allowance (RDA’s) for Vitamin D (IU’s)
Age Male Female Pregnant Lactation 0-12 months 400 1-13 years 600 14-18 years years years > 70 years 800 Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010.

National Osteoporosis Foundation: March 2011 Recommendations
Calcium and Vitamin D Recommendations Children & Adolescents Calcium (Daily) Vitamin D (Daily) 1 through 3 years 500 mg 400 IU* 4 through 8 years 800 mg 9 through 18 years 1,300 mg Adult Women & Men 19 through 49 years 1,000 mg IU 50 years and over 1,200 mg IU Pregnant & Breastfeeding Women 18 years and under 19 years and over * These are the recommendations of the American Academy of Pediatrics.

Food Sources of Vitamin D
Serving Size Vitamin D (IU) Sunshine 5-15 mins Varies; see your doctor for advice on sun exposure Cod liver oil 1 T 1360 Wild-caught salmon, Sockeye 4 oz 739 Wild-caught salmon, Chinook 411 Mackerel 3 ½ oz 345 Sardines 1 ¾ oz 250 Tuna fish 3 oz 200 Soy Milk 1 cup 120 Milk, nonfat/reduced fat/whole/vitamin D fortified 98 Margarine, fortified 60 Ready-to-eat cereals fortified with 10% of the DV for vitamin D ¾ to 1 cup (depending on the brand) 40 Egg 1 whole 20 Liver, beef, cooked 15 Cheese, Swiss 1 oz 12

Food Sources of Calcium
Serving Size Calcium (mg) Yogurt, plain low fat 1 cup 415 Orange juice, calcium fortified 6 fluid oz 378 Mozzarella Cheese, part skim 1.5 oz 333 Sardines, canned in oil, with bones 3 oz 32 Cheddar Cheese 306 Yogurt, fruit low fat Milk (nonfat, low fat 1%, reduced fat 2%, whole 3.25%) 272 – 296 Tofu, firm made with calcium sulfate ½ cup 253 Tofu, soft made with calcium sulfate 138 Salmon, pink, canned, solids with bones 181 Cottage cheese, 1% milk fat Turnips greens, boiled 99 Kale, raw/cooked 90/94 Soy beverages, calcium fortified Ice cream, vanilla 84 Chinese Cabbage, raw 74 Tortilla, corn, ready-to-bake 1 medium 46 Broccoli, raw 21

Calcium Supplementation
Calcium supplements should not be taken at the same time as iron supplements. Medications that need to be taken on an empty stomach should not be taken at the same time as a calcium supplement. Calcium is absorbed best when taken in amounts of 500 – 600 mg or less. Calcium comes in four forms calcium carbonate, calcium citrate, calcium phosphate and calcium lactate. Each have different amounts of elemental calcium – always check label Calcium citrate more easily absorbed Calcium carbonate better absorbed on an empty stomach Calcium can interfere with absorption and action of other medications – always check with your health care provider &

Choosing a Multivitamin
A must - Be sure it contains: B1 (thiamin) B2 (riboflavin) B3 (niacin) folic acid Vitamin D Ideal Zinc and iron If you are not taking the recommended number of servings of Calcium Calcium supplement as the multivitamin with mineral will never have enough calcium if you are taking < 75% of the recommended number of servings Check the percentages. Greater than 100% of any vitamin or mineral should be checked by your health care provider

Continued GI Symptoms Inadequate fiber Intake Carbonated beverages
FODMAPS and other fermentable carbohydrates Food Allergens

FODMAPS

What are FODMAPs

Characteristics of a FODMAP
FODMAPs - small chain sugars/carbohydrates and fiber poorly absorbed in small intestine - delivered to the large intestine small osmotically active molecules food for bacteria – when eaten gas is produced – fermentation Poorly absorbed, rapidly fermentable, osmotically active dietary carbohydrates (FODMAPs)

What does FODMAPs stand for ??
F is for Fermentable - Carbohydrates that are fermented by bacteria in the large intestine instead of being broken down by our digestive enzymes Fermentation results in gas, bloating and pain. O is for Oligosaccharides - Oligosaccharides are short-chain carbohydrates - Fructans - Fructooligosaccharides (FOS) - Oligo-galactans Xylo-oligosaccharides

What does FODMAPs stand for ?
D is for Disaccharides - These are pairs of sugar molecules Lactose, maltose M is for Monosaccharides - This describes a single sugar molecule Fructose, glucose, galatose, xylose A is for And - Every list needs a good conjunction. P is for Polyols - Polyols include sugar alcohols like xylitol, sorbitol, or maltitol.

Carbohydrate Why they might cause an issue Disaccharide Found in milk. Lactose intolerance is caused by partial or complete lack of the enzyme lactase.. Monosaccharide Found in fruit. Fructose intolerance is is due to incomplete digestion in the GI track. The absorption of fructose is dependent on glucose. Monosaccharaides are poorly absorbed due to their low capacity transport across the epithelium. Low expression of GLUT5. Fructans Oligosaccharide Fructans are completely malabsorbed because the intestine lacks an enzyme to break their fructose-fructose bond. Wheat accounts for the majority of peoples fructan intake. Galactans Oligosaccharide Found mostly in beans and lentils. Galactans are malabsorbed as the intestine does not have the enzyme needed to break down galactans. Polyols Found naturally in some fruits and vegetables and added as sweeteners to candy, gum and meds. Polyols are too large for passive diffusion.

A: Poorly absorbed CHO arrives in colon populated with microbiotia
Shepherd S et al. Short-Chain Carbohydrates and Functional Gastrointestinal Disorders. Am J Gastroenterology. 2013;108: A: Poorly absorbed CHO arrives in colon populated with microbiotia B: Osmotic activity leads to increase water retention in lumen of the small and large bowel C: CHO is a substrate for bacterial fermentation, resulting in the rapid product of gas and luminal distention

Fructans & (FOS) Fructooligosaccharides
IntroductionFructans are a large group of carbohyawates. Chemically fructans are polymers of fructose. They were first described by Rose, a German scientist, who found “a peculiar substance from plan origin in a boiling water extract from Inula helenium" in This substance was named inulin by Thompson in 1818.Fructan is an important and widespread non-structural carbohydrate that can be found in plants, algae and bacteria. Fructans are the dominant carbohydrate reserve in several families of the plant kingdom.Fructans, especially inulin, are presently used in functional foods and as soluble fibres.Fructan chemistryPlant fructansBacterial fructansApplications Fructan chemistryFructans have a general structure of multiple fructose units, with or without a single glucose molecule at the beginning. In plants up to 1000 fructose units can be linked in a single fructan-molecule. Bacterial fructans can consist of up to fructose units. The structure of fructans and fructan-derived oligosaccharides is generally abbreviated as GFx , with G indicating a glucose unit and Fx the number of fructose units. The number of glucose/fructose units is the Degree of Polymerisation (DP). Fructan derived oligosaccharides generally have a DP<10.There are several types of fructans present in nature. These types are distinguished on the basis of the glycosidic linkages by which the fructose residues are linked to each other. They can broadly be divided into 3 groups; the inulin type, the levan type and the graminan type.InulinsThe first group are the inulins, which are linear fructans, where the fructose units are (mostly) linked via a beta(2->1) bond. Nearly all fructans found in plants are of this type. The picture below shows 1-kestose. This is the shortest fructan of the inulin type. In larger fructans the coupling of fructose units is similar to the second fructose link to the first in the picture.

Galactans (GOS) (oligosaccharides)
Two types raffinose and stachyose

Lactose (disaccharide)

Fructose (monosaccharide)
Food Fructose (gms) (per 100 g food) Glucose (gms) Excess Free Fructose Verdict Honey 40 30 10 Problem Kiwi 4 Suitable Pineapple 5 Mango 3 1 2 Watermelon Asparagus .65 .35 Problem?

Polyols Sorbitol- more common in fruits
Mannitol-more common in vegetables Added as a sweetener in many “low-calorie foods” especially sugar free gum and toothpaste”

Sorbitol Item Portion size Sorbitol content (gms) Prunes .25 cup 9
Dried Apricot .5 cup 4.1 Dried Pear 6 pieces 2.2 Sugar-free gum 2 pieces 4 Plum 1 1.6 Apricot 1.3 Apple Juice 1 cup 1.1 Dried Apple .9 Wasabi 1 teaspoon .6 Cherries 5 .3 Coconut Milk Dried coconut .2 J Hum Nutr Diet apr;27 Suppl 2:263-75

Mannitol content of foods
Item Portion size Mannitol (gms) Cauliflower 1 cup 3.4 Celery 1.9 Mushrooms Snow Peas 10 pods .4 Sweet Potato .3 Pomegranate 1 fruit .2

Evidenced Based?

Candidate for Low FODMAP
Symptoms Bloating Belching Distention Gas Abdominal pain Nausea Diarrhea

Implementing the diet Complete elimination is the most efficient method of assessing responsiveness. 2 week MINIMUM to determine whether it will be helpful 6 to 8 week of strict avoidance prior to FODMAP challenge Candidates for partial reduction Very picky eater, unwilling to eat low FODMAP foods Dietitian has identified foods/beverages that are contributing significant FODMAPs

Suitable Alternatives (limit to ½ cup serving per meal/snack)
FODMAPs Foods High in FODMAPs Suitable Alternatives (limit to ½ cup serving per meal/snack) Excess fructose and polyols Apples (Juice) Apple Sauce Cherries (Juice) Pears (Juice) Fruits packed in Juice Firm bananas Blueberries Cantaloupe Clementines Grapes Honeydew melon Kiwi fruit Lemon juice Mandarin oranges Navel oranges Pineapple Raspberries Rhubarb Strawberries Excess fructose Ripe bananas Mango Polyols Blackberries Peaches Oligosaccharides Dried cranberries Dried dates Dried pineapple Grapefruit (Juice) Persimmon Pomegranate Raisins Oligosaccharides and Polyols Nectarines Oligosaccharides, Fructose, and Polyols Watermelon

Suitable Alternatives Excess fructose Asparagus Arugula Bean sprouts
Vegetables FODMAPs Foods High in FODMAPs Suitable Alternatives Excess fructose Asparagus Arugula Bean sprouts Bok choy Broccoli Brussel sprouts (small serving) Carrot Common cabbage (not Savoy cabbage) Cucumber Eggplant Fennel bulb and leaves Green beans Green pepper Kale Lettuce Okra Parsnips Radish Red pepper Spinach Spring onion tops Tomato Turnip White potato Yellow summer squash Zucchini Polyols Cauliflower Celery Corn Mushrooms Snow peas Sweet potato Oligosaccharides Artichokes Beet Garlic (as a flavoring) Leek bulb Onions (as a flavoring) Shallots and polyols Butternut squash (moderately high)

White Bread (made from wheat) Buckwheat Corn Millet Oats Quinoa Rice
FODMAP Foods High in FODMAPs Suitable Alternatives Oligosaccharides (fructans) Barley Rye Rye-based bread Rye-based cereals Wheat Wheat-based bread Wheat-based cereals Wheat-based pasta White Bread (made from wheat) Buckwheat Corn Millet Oats Quinoa Rice Rice bread Rice or corn-based pasta

FODMAP Foods High in FODMAPs Lactose (gm) Suitable Alternatives Lactose Milk (1 cup) Evaporated milk Sweetened condensed milk Yogurt 9-14 24-28 31-50 4-17 Lactaid milk (1 cup) Yoplait lactose-free vanilla yogurt Green Valley lactose-free yogurt Cottage cheese (1/2 cup) 0.7-4 Lactaid cottage cheese American cheese (1 oz) 0.5-4 Cheddar cheese (1 oz) Ricotta cheese (1/2 cup) 0.3-6 Mozzarella, part-skim (1 oz) Ice cream (1/2 cup) 2-6 Lactaid Ice cream Butter (1 pat) Cream cheese

FODMAPs Foods High in FODMAPs Oligosaccharides – galactooligosaccharides (GOS) Dried split peas Baked Beans Black Beans Kidney Beans Cannellini Beans Great Northern Beans Pinto beans Navy beans Lima beans Veggie-burgers soy, Edamame Soy milk if made from whole bean Pistachios Cashews Nuts: (limit to small handful per sitting) almonds, peanuts, pecans, walnuts, sunflower seeds Tofu Tempeh Canned and Drained: < ½ cup Chickpeas < ½ cup Lentils During Reintroduction phase use of Beano is recommended Soy milk made from Soy protein Other items to consider Sorbitol Sugar free chewing gum Pepsi, Coke, other regular sodas Sugared Chewing gum (chewing gum can add to gas) Pepsi Throwback (caution with carbonation as that can add to gas)

Reading Food Labels – Shopping tips
Look out for Inulin – this is added to many yogurts, cream cheese, organic valley vanilla milk, rice milks Organic Inulin exists Look out for High Fructose Corn Syrup: this is added to as a sweetner in beverages and as a browning agent in baked products. There is currently no organic sources of HFCS Metamucil is 100% inulin. An alternative would be psyllium husk. GF Is a good starting point as they are wheat free but make sure they don’t have apple, pear, honey or molasses Apple juice and pear juice are often added to GF products to sweeten them. Beware as apples and pears are high in sorbitol. Low polyol sweeteners are aspartame, stevia (some have added inulin), sugar (sucrose) and maple syrup. Onion powder and garlic powder – often added to salad dressings and broths. “Natural Flavoring” is often onion and garlic.

Ingredients to Avoid Agave syrup Apple juice Brown rice syrup Bulgar wheat Chicory root extract Crystalline fructose Dry milk solids Fructo-oligosaccharides (FOS) Fructose Fructose solids Fruit juice concentrates Garlic Glycerin High-fructose corn syrup Honey Hydrogenated starch hydrolysates Inulin Isomalt Lactatol Lactitol Lactulose Maltitol Mannitol Miso Molasses Onion Pear juice Polydextrose Sorbitol Tomato paste Whey protein concentrate (unless lactose-free) Xylitol

Pointers during Elimination phase
Gluten-free is not always FODMAP friendly look for the inulin and High Fructose corn syrup and honey , molasses and fruit juice sweetened. ? Guar gum. Unless the client has Celiac Disease the diet DOES NOT NEED TO BE GLUTEN FREE Green tops of leeks and green onion adds flavor without significant FODMAP There is no evidenced that FODMAP ingestion results in damage to the intestine Fiber is very important and often missing, If the have IBD-C be sure to add flaxseed, Chia and Citracel Even though Fat is not a FODMAP it can be a trigger Even though Caffeine and carbonation are not FODMAP, they can be a trigger.

Some suitable milk substitutes
Ingredients: Fat Free Soymilk (Water, Soy Protein)

Ingredients: water Osmosis reverse, soybeans(s) organic
Water Filtered, soybeans whole

Challenge Phase 3 week trial of Strict Low-FODMAP
Continue for 6 to 8 weeks if significant symptom improvement Map out a challenge that works for each client. If they don’t care Trial of Lactose first, as lactaide can be used Trial of GOS (raffinose) as Beano can help Trial of fructose as glucose can be used to facilitate absorption Fructans are the hardest and in my personal experience the least well tolerated.

IN MY OPINION: Biggest offenders
Lactose: only if you are lactase deficient Fructans: large amount so wheat, onion and garlic avoiding wheat is probably why the SCD, Paleolithic and wheat belly are popular Fructose: High Fructose Corn Syrup, honey, mango, Polyols: Sorbitol in sugar free gum and toothpaste, apple and pears and products packed with apple and pear juice

Unanswered Questions Long-term safety Nutritional adequacy of the diet
Effect on Microbiota (reduction of natural prebiotics) Effect on colorectal carcinogenesis Effect on physiology of the bowel Does it change visceral hypersensitivity Mechanisms of action in Induction of fatigue Increasing gastro-esophageal reflux

Final Thoughts The FODMAP diet is now viewed as evidence-based first-line treatment strategy for patients with IBS. - scientifically proven provides all the nutrients needed - reduces symptoms of IBS in ¾ of IBS suffers won’t cure IBS but it does help to prevent trigger symptoms should be prescribed by a dietitian who is an expert there is high compliance to the diet – if diet is delivered well

When you need to seek additional Help
Concerns about weight and or growth Continued GI symptoms on a strict GFD Persistently elevated celiac blood work

Questions?? Thank you

Beyond the Gluten-Free Diet: What Foods Are Right for Me?

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