Fall 2013

Research Update

Fall2013-Research

Type 1 diabetes and celiac disease: The effects of gluten free diet on metabolic control.

Highlights: Celiac disease occurs in at least 10% of patients with Type 1 diabetes at some point in their life. Patients should be screened for celiac disease at diagnosis and yearly. Fortunately, celiac disease does not appear to worsen glycemic control or diabetic complications. However, gluten-free diet compliance is lower in patients with both diseases compared to celiac disease alone – indicating significant challenges faced by these patients. Many gluten-free foods have a high glycemic index (made with refined starches and flours) and would not be appropriate for type 1 diabetes. Expert dietitian assessment and education is critical.

Application to Dietetic Practice: This article was written by a physician for physicians. Fortunately, the importance of expert dietary counselling is stressed. It would be a good overview article for dietitians that counsel celiac and/or type 1 diabetic patients. However, it does not provide specific nutrition counselling details.

Web Link

Why do few food-allergic adolescents treat anaphylaxis with adrenaline? Reviewing a pressing issue.

Highlights: Adolescents are at increased risk for fatal food allergic reactions, because they are gaining responsibility to decide what to eat and be prepared to treat an allergic reaction without parental supervision. It is common for this group to not use their adrenaline auto-injector* at the start of an allergic reaction. Reasons include: not carrying it, not knowing when to use it (i.e. what symptoms), peer/social pressure, etc. The current research and practical strategies to counsel adolescents are presented.*The article was written in the UK. In Canada and the US, we would refer to an epinephrine auto-injector.

Application to Dietetic Practice: All health care professionals working in anaphylaxis education would benefit from this article. Anaphylaxis education is usually done by nurses, but dietitians could take on this role. Parents with the appropriate literacy skills may find this article helpful.

Pub Med Link

Resources Update

Fall2013-Resources

Gluten-Free Food Labeling (US)

Description: The Food and Drug Administration has recently issued a final rule regarding “gluten-free” labelling. In summary, wheat, rye and barley are gluten-containing grains. “Gluten-Free” claims cannot be used if the product:

  • contains a gluten grain (exception: gluten has been removed in processing, e.g. wheat starch)  OR
  • contains greater than 20 parts per million (ppm) of gluten. This may occur through cross contact during manufacturing or use of ingredients that have been processed to remove gluten, but residual levels remain. This final rule only applies to foods and dietary supplements that are regulated by the FDA.  Foods regulated by the Department of Agriculture (USDA) and the Alcohol and Tobacco Tax and Trade Bureau (TTB) are not affected by this rule (although many companies follow it voluntarily).

Note: I’ve been to several small bakeries and restaurants that use “gluten-free” inappropriately.  Many eateries have started making gluten-free products to capitalize on the growing market, but do not recognize the risk of cross contact (contamination). Even if the ingredients are gluten-free, the product will very likely exceed 20 ppm of gluten if it is made in a facility that uses wheat flour. Wheat flour dust can remain suspended in the air for up to 48 hours, gradually settling on kitchen counters, appliances, etc. Even with very thorough cleaning, it is difficult to remove all traces of wheat flour. Under these circumstances, a restaurant/bakery would need to test their food and only label as gluten-free if the product was consistently below 20 ppm. I always ask restaurants how their gluten-free products were made and provide information when necessary.

Target Audience: Consumers and professionals.

Organization: Food and Drug Administration website

Website Link: www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Allergens/ucm362880.htm

Tax Tips for Celiac Clients (US)

Description: Clients diagnosed with celiac disease may be able to claim the additional cost of a gluten-free diet and admission/transportation to education events. Celiac clients should discuss this information with an accountant.

Target Audience: Patients diagnosed with celiac disease

Organization: Celiac Disease Foundation (many websites have this information)

Website Link: http://celiac.org/celiac-disease/resources/tax-deductions/

Gluten-Free Food Labeling (Canada)

Description: The Canadian government has not released regulations regarding gluten-free labelling, but Canadian dietitians may be asked about this topic with the media attention surrounding the new US regulations. Under the Enhanced Labelling for Food Allergen and Gluten Sources and Added Sulphites, the presence of wheat, barley, rye, etc. must be clearly indicated on the label, even if it is an ingredient of another ingredient. However, this legislation applies only to ingredients that are intentionally added, not to the unintentional presence of gluten through cross contamination during manufacturing. Health Canada’s position is that a food product would have to have less than 20 parts per million of gluten to use the “gluten free” claim. Companies need to test their products to ensure they are below this threshold.

Note: I’ve been to several small bakeries and restaurants that use “gluten-free” inappropriately.  Many eateries have started making gluten-free products to capitalize on the growing market, but do not recognize the risk of cross contact (contamination). Even if the ingredients are gluten-free, the product will very likely exceed 20 ppm of gluten if it is made in a facility that uses wheat flour. Wheat flour dust can remain suspended in the air for up to 48 hours, gradually settling on kitchen counters, appliances, etc. Even with very thorough cleaning, it is difficult to remove all traces of wheat flour. Under these circumstances, a restaurant/bakery would need to test their food and only label as gluten-free if the product was consistently below 20 ppm. I always ask restaurants how their gluten-free products were made and provide information when necessary.

Target Audience: Consumers and professionals.

Organization: Health Canada website

Website Link: www.hc-sc.gc.ca/fn-an/securit/allerg/cel-coe/gluten-position-eng.php

Tax Tips for Celiac Clients

Description: The additional cost of a gluten-free diet may be used as a medical expense and claimed as an income tax deduction (depending on income). Celiac clients should discuss this information with an accountant.

Target Audience: Patients diagnosed with celiac disease

Organization: Canada Revenue Agency website

Website Link: www.cra-arc.gc.ca/tx/ndvdls/tpcs/ncm-tx/rtrn/cmpltng/ddctns/lns300-350/330/clc-eng.html

Your Clinical Questions

Fall2013-Q&A

Are the results of IgG blood testing valid?

IgG is a type of antibody produced by the immune system. IgG to specific foods circulate in the blood, and many practitioners claim this causes poor health. However, several research studies have not supported this theory. The Guidelines for the Diagnosis and Management of Food Allergy in the United States does not recommend IgG testing in clinical practice. Note: IgG and IgE blood tests are two completely separate tests.

If someone is allergic to peanut, can they eat tree nuts?

Clients need to discuss this question with their allergist. A client may be advised to restrict all nuts for two reasons: 1) Cross contamination (cross contact):  Tree nuts are often processed on the same equipment as peanuts. 2) Cross reactions:  A peanut allergic client is allergic to a specific protein in peanut. Any tree nuts with the same protein will cause a reaction.   A peanut allergic client can eat tree nuts if their allergist has approved it (many allergist perform food challenges with specific nuts) AND there has been no contact with peanut (eating nuts right out of their shell prevents cross contamination).