Citation: Dudeja P, Singh A. Let Food be your Medicine and Medicine Be Your Food: A Step Forward for Celiac Disease Cases. Indian J Nutri.2016;3(1): 118.

Introduction

The age old adage of iceberg phenomenon applies aptly to CelaicDisease (CD) which often remains under diagnosed in our OPDs.Recent studies on prevalence of this menace has documented thatthe burden is progressively on the rise. Epidemiologically, the diseasefollows a specific place distribution with higher burden in Northernparts of the country the so called “celiac belt” than southern part[1,2]. The disease has commonly been reported from states of Punjab,Haryana, Delhi, Rajasthan, Uttar Pradesh, Bihar and Madhya Pradesh.This can be ascribed to both due to wheat consumption as staple inthese states and the population possessing haplotypes necessary forceliac disease to develop. As far as the age distribution is concerned thedisease was thought to affect more children than adults [3,4]. On theother hand some studies in US have highlighted increased prevalenceof CD in elderly [5,6]. About 6-8 million Indians are estimated tohave CD. Since, many cases of CD remain undetected in the country;it clearly indicates the number is still underestimated to some degree.Diagnosis of CD involves case identification through history taking,screening tests and confirmatory tests. Makharia et al. in theirprevalence study in national capital region applied this three stepclinical/serological screening procedure and reported the prevalenceof CD to be 1.04% (1 in 96) and of positive anti-transglutaminaseantibodies (anti-Ttg) to be 1.44% ( 1 in 69) [7]. In another study, aquestionnaire based survey was carried where out of 4347 children(3-17 years) from Ludhiana; the prevalence was 1 in 310 [8]. Howeverroutinely in OPDs only those with typical clinical symptoms with orwithout family history get the required attention whereas those withmilder symptoms failed to get screened [9]. Another dilemma with

screening tests is that the kits for these tests are not manufactured in India and are imported from Europe. The positive predictive valueof these tests which is based on the prevalence of disease in Europedoesn’t apply to India population [10].

Understanding the basics: What is Gluten?

Hippocrates said ‘all disease begins in the gut’. This appliesstrongly to gluten in wheat, barley and rye which can gradually erodethe villi of small intestine, prohibiting body from absorbing nutrientsfrom food. Gluten is the collective term used to describe storageproteins in grains - wheat (gliadin), barley (hordein) and rye (secalin).The protein content of wheat varies between 8% and 17% dependingon the genetic makeup and external factors associated with the crop.When wheat flour is mixed with water, the insoluble protein fractionforms a viscoelastic protein mass called the Gluten [11]. Actually, thename gluten is derived from these glue-like properties. Gluten whichcomprises 78 to 85% of the total wheat protein is a very large complexmainly composed of polymeric & monomeric proteins. Gluten isclassified into two main fractions according to its solubility in aqueousalcohol, the soluble Gliadin and the insoluble Glutenins. The Gliadinshave high protein and glutamine content. Some humans essentiallylack endo peptidases to cleave bonds between proline & glutamines.This incomplete digestion of Gliadin by digestive tract enzymeleads to generation of many polypeptides which are immunogenicto patients genetically susceptible to CD. Some patients who don’tdevelop CD do manifest gluten sensitivity called as non celiac glutensensitivity or present as irritable bowel syndrome [12,13].

Gluten intake varies from population to population and dependsupon dietary practices. Wheat is the staple cereal in the northern parts of the country and flat bread (chapati/ roti) made from wheatflour is one of the most important constituents of almost every meal.A typical North Indian diet where flat bread is the usual meal containsabout 25-30 gm of gluten/day.

The Panacea: Gluten Free Diet

Presently, the only treatment for celiac disease is a strict exclusionof gluten sources including wheat, rye, barley and their hybridizedforms from the diet [14,15]. The absence of Gluten in natural andprocessed foods represents a key aspect of the Gluten Free Diet(GFD). In 2000 the Codex Alimentarius and FAO described GlutenFree foods with Gluten level not exceeding 20 ppm and consisting ofor made only from ingredients which do not contain any prolaminesfrom wheat or any triticum species such as rye, barley and oats. Thenorthern part of our country with wheat as the preferred cerealof consumption poses a challenge in terms of compliance. Crosscontamination of food with gluten and without gluten can occuranywhere from farm to fork i.e during milling, at the grocery storeif the same spatula is used to pick grains, at factories if the sameproduction line and equipment are used or at home if the sameutensils are used for storage and preparation of different cereals.Such processes pose a big challenge in our routine lives. To face thisproblem Food safety and Standards Authority of India (FSSAI) havebrought a ray of hope for those prescribed with GFD as the treatmentfor all their problems. The new regulation proposed and passed hasdefined the parameters for “Gluten Free Foods” where the maximumlimits for Gluten in Gluten free foods have been defined. These are asgiven below:-

Gluten Free Foods: The FSSAI definition

a. These foods consist of or are made of one or more ingredients,which may contain rice, rye, barley, oats & millets or ragi, pulses andlegumes, where the inherent gluten has been reduced and the glutenlevel does not exceed 20 mg/kg in total based on the food as sold ordistributed to the consumer.

b. The product does not contain wheat or any of itsingredients and shall bear the label declaration. The labellingof food products containing Gluten or being Gluten Free will alsobe reflected in the FSS (Packaging & labelling) regulations 2011. AllGluten free products will have a printed term “Gluten Free” in theimmediate proximity.

c. A food by its nature is suitable for use as part of Glutenfreediet shall not be named as “special dietary” or “special dietetic”or any other equivalent term. However, such food may bear astatement on the label that “this food is by its nature gluten-free”.

Foods specially processed to reduce gluten content to a levelabove 20 up to 100 mg/kg.

These foods consist of one or more ingredients from rice, rye,barley, oats, millets or ragi, pulses and legumes which have beenspecially processed to reduce the inherent gluten present in them toa level above 20 up to 100 mg/kg in total based on the food as soldor distributed to the consumer and shall bear the label declarationas provided in the sub regulation 2.4.5(53) of the Food safety andStandards (Packaging & labelling) Regulation, 2011.

The limits of less than 20ppm of gluten set by FSSAI in Indiaare in accordance with those by The Australia New Zealand FoodStandards Code. However they have a risk management strategyalongside which says in case gluten levels are equal to or greater than20 and less than 100 then product withdrawals is requested togetherwith a review of procedures and/or labelling and an investigationinto the origin of the gluten. In extreme cases with gluten levels ofmore than 100 ppm product recall is done immediately. U.S. Foodand Drug Administration (FDA) issued a similar regulation in 2013that defined the term “gluten-free” for food labelling. A numberof other western countries also have ruled on this matter, and haveimplemented the 20 ppm level indicated in the Codex Alimentariusstandard. This measure has been effective since January 2012 in theEuropean Union (and was announced in August 2013 by the US-Foodand Drug Administration. Table 1 describes comparison of glutenfree claims in Canada, US and India.

The availability of GF foods is a factor which will allow for a farbetter compliance to GFD. However, the economic aspect in terms ofaffordability of GF food may act as a major deterrent keeping themout of reach for the masses.

Various studies have documented that the time of first exposureto wheat influences the development of celiac disease [16]. Incountries such as Finland, Estonia, and Denmark, characterizedby low gluten consumption in infancy, celiac disease prevalence ismuch lower than in Sweden where gluten consumption is high ininfancy. The Committee on Nutrition of the European Society forPaediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)recommends that it is prudent to avoid both early (less than 4 months)and late (7 or more months) introduction of gluten and to introducegluten while the infant is receiving breast milk and not formula orbovine products [17]. The current National Guidelines on Infantand Young Child Feeding (IYCF) by Ministry of Human ResourceDevelopment; department of Women and Child Development,government of India 2004 are in consonance with above saidrecommendations. According to IYCF Porridge made with suji,broken wheat, wheat flour, ground rice should be introduced at 6months of age. This not only ensures healthy feeding of the infantbut also serves as primary prevention for celiac disease. Publichealth specialists can play their part in prevention of CD throughimplementation of infant feeding recommendations and take thisopportunity to avert the impending epidemic of CD.

Mineral analysis: Iron (Fe), Zinc (Zn), Potassium (K), Calcium(Ca) and Sodium (Na) were determined using Atomic AbsorptionSpectrophotometer and Flame Photometer according to IITA, (2002).